Special Moments – Enquiry

Clients must meet the following criteria:

Be aged 18 years or older.
Have a terminal diagnosis and are currently receiving palliative or end-of-life care (as confirmed by their GP or treatment specialist), or are also a patient residing in a medical facility for a long period of time.
Require specialised medical transport to revisit their place of personal significance.
Clients must have the approval of their treating clinician prior to undertaking the journey. This can be a GP or specialist.
If clients have complex health care needs beyond the abilities of our volunteers, we ask that a qualified health practitioner accompany them on the journey (please don’t worry if you are unsure, we will discuss this with you).

Patient Information

Patient's Full Name *

Patient's Age *

Patient's Date of Birth *

Patient's Gender

Contact number if able to participate in planning the journey

Residence name (if a facility)

Address *

Suburb *

State *

Postcode *

Contact Person Information

Full Name *

Relationship to Special Moments patient *

Contact Number *

Email Address *

Special Moment request

Desired location *

Please provide us with some details as to the significance of the location/occasion *

Service Goals of Care Agreement

The Special Moments service is volunteer run and all journeys are subject to the availability of volunteers and suitable vehicles.
St John Ambulance Victoria is only able to transport patients in non-life-threatening circumstances to places of personal significance. If a client’s condition deteriorates during the journey, volunteers can provide basic life support only, and will request an ambulance by calling triple zero.

Only clients, their carers or family members or an accompanying qualified health practitioner can administer client medication