Yes No



  • is travelling against the advice of a physician;
  • has been diagnosed with or been given a life expectancy of 6 months or less;
  • has been prescribed and/or used home oxygen within the past 12 months
  • has been prescribed or recommended the use of dialysis in the last 12 months;
  • are under 15 days old, or are older than 89 years of age;
  • resides in a nursing home, home for the aged, other long-term care facility or rehabilitation center; or
  • requires assistance with activities of daily living

Yes No