Woodlands Club Registration Form - Woodlands Care Home

Name *

Gender: *

Male
Female

Date of Birth *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Other Comments

NEXT OF KIN /EMERGENCY CONTACT DETAILS

Name of Next of Kin *

Address *

Address Line 1

City

State / Province / Region

Postal Code

Phone *

Mobile Number *

Email *

Relationship *

2nd Emergency Contact

2nd Name of Next of Kin *

Phone *

Mobile Number *

Email *

GENERAL PRACTITIONER DETAILS

GP's Address *

Address Line 1

City

State / Province / Region

Postal Code

NHS Number *

Have you received the COVID 19 vaccine? *

Vaccine 1
Vaccine 2
Booster 1
Booster 2

(please tick appropriate box)

Please provide details of vaccine status *

Special Dietary Requirements

Dietary Requirements *

Allergies *

Do you require assistance with: *

Eating
Toilet
Mobility
Transport

Please provide explanation of needs

INVOICING & PAYMENT DETAILS

Self Funding
Social Services

(please tick appropriate box)

Name *

First

Last

Address Line 1

City

State / Province / Region

Postal Code

Days missed will not be refunded for any reasons other than *hospitalisation and Covid.

Please tick to confirm you have read and agreed

Days Attending

Start Date *

Please select Days attending *

Monday
Tuesday
Wednesday
Thursday
Friday

Rate Per Day is £90

Should you wish to no longer attend the Woodlands Club, one week's notice will need to be given. Accounting will be up to the period of notice.

Please tick to confirm you have read and agreed

Medical Questionnaire

Please Select Yes or No

Do we have your permission to resuscitate the client? *

Do we have your permission to administer your EpiPen in the event of Anaphylactic reaction? *

Yes
No
Not Applicable

(Please Supply EpiPen)

Do we have your permission to administer Aspirin to the client in the event of a heart attack? *

Do we have your permission to administer Paracetamol to the client in the event of a headache or anything requiring pain control? *

Do we have your permission to administer GTN spray to the client when required if they have been diagnosed with angina or a heart condition? *

Yes
No
Not Applicable

(Please Supply GTN spray)

Are you currently on blood thinners? *

Please supply an up to date current list of medication, this will help us in the unlikely event of the emergency services being called to the centre. It is the responsibility of the family to inform and update Woodlands Club of any changes with regard to medication.

Any other comments/Notes

Please tick to confirm you have read and agreed

Medical Conditions

Please tick next to any medical condition listed below which you have been diagnosed with. Please also note year (if known) of diagnosis. The list is extensive to help ensure that we have a complete history, please do not be concerned if you do not recognise all of the terms:

Hypertension (High blood pressure) *

Diabetes *

High Cholesterol *

Heart and Related Disorders

Angina *

Any other heart condition *

Neurologic Disorders

Stroke *

If yes, please provide further details

Dementia *

If yes, please provide further details

Parkinson's Disease *

If yes, please provide further details

Miscellaneous

Incontinence *

If yes, please provide further details

Where did you hear about us? *

Search engine (Google, Yahoo, etc.)
Recommended by friend or colleague
Care Service
Social Media
Advert/Press
Other

Other: *

Please let us know how you heard about us if not selected above.

Tel: +44 (0)1895 634 830

Tel: 01895 634 830

NEXT OF KIN /EMERGENCY CONTACT DETAILS

2nd Emergency Contact

GENERAL PRACTITIONER DETAILS

Special Dietary Requirements

INVOICING & PAYMENT DETAILS

Days Attending

Rate Per Day is £90

Medical Questionnaire

Medical Conditions

Heart and Related Disorders

Neurologic Disorders

Miscellaneous