Visitor Exemption Request Form

Currently there are entry restrictions for visitors. Please complete this form to apply for an exemption.

In accordance with Queensland Health Hospital Entry Direction (No. 7), all visitors must be fully vaccinated against COVID-19. Exemptions for unvaccinated persons entering hospitals can only be granted for the following purposes:

End of life visit
In an emergency
A parent, carer, guardian or other responsible adult who is accompanying a child or person with a disability that is a patient of the hospital

Applications must be submitted at least two business days prior to entry. We will respond to your request as soon as possible.

Please note: This form is for inpatient visits only. If you are attending a specialist appointment, please contact your doctor for visitor requirements at their private rooms.

VISITOR INFORMATION

Name

Telephone

Residential address

Email address

Relationship to patient

Are you fully vaccinated against COVID-19? YES OR NO

Yes
No

Reason for exemption (choose one)

End of life visit
To be a support person during birth
In an emergency
A parent, carer or guardian of a child who is a patient of the hospital
A carer or other responsible adult accompanying a person with a disability who is a patient of the hospital
Other - please provide details:

Exemption applications for reasons other than those listed above may be submitted for consideration, however please note approval cannot be guaranteed. We thank you for your understanding.

Proposed visit date/s and duration:

PATIENT INFORMATION

Patient Full Name

Date of birth

Name of Doctor caring for patient

Area of visitation

e.g. Ward (provide ward name), theatre, medical suites

PLEASE NOTE:

Unvaccinated parents, carers, guardian or other responsible adult, and those visiting in an emergency situation will need to comply with risk mitigation measures put in place by the hospital.
This includes testing requirements, use of single use masks, physical distancing measures.
Only one unvaccinated parent, carer, guardian or other responsible adult will be permitted at a time.

Visitor Exemption Request Form

VISITOR INFORMATION

PATIENT INFORMATION

PLEASE NOTE:

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