S P Registration Form

Please Answer All Questions or Call us on 01889 800565 to Arrange an Assessment at Home

Service User Name*

Service User Address*

Service User Telephone*

E Mail Address*

Service User Date of Birth*

GP Name/ Surgery*

Any Allergies to Food/Medication*

Past Medical History*

Emergency Contact (Name/Number)*

Name/Contact Number of Person Completing this Form*

I will be using a wheelchair at all times during the session

I will need to wear an incontinence pad during the session

I will need someone to book me a Taxi to get home

I have a DNAR order in place

I have other needs I wish to discuss further (in addition to questions below)

I understand there is a charge of £27.50 per session for this service

What problems do you have with your sight, hearing or speech (if any)?*

What problems / concerns do you have with your memory (if any)? *

What equipment will you bring with you to help you move/stand/transfer (if any)?*

What help will you need with eating or drinking? Do you have any special dietary requirements? *

What help will you need to use the toilet facilities (if any)?*

What help will you need with your medications at lunchtime (if any)? *

I agree that my data entered in this contact form will be stored electronically, and will be processed and used for the purpose of establishing contact and for health purposes in case of an emergency. I am aware that I can revoke my consent at any time. If completing on behalf of someone else you are confirming that you have gained consent from the proposed service user to complete this form on their behalf (or have legal power of attorney).

Note: Fields marked with * are required

Please be aware that the contents of this form are not encrypted