Postcards

In order to ensure we can give you the best care, please fill this form in when you have a moment. If you should ever need an ambulance, you can just hand this to the Ambulance crew. This will help us give you the best care. There is an option to e-mail it should you wish to send a copy to a carer/relative/friend.

 

First Name:..........................................I like to be called:..........................................

Surname: ..............................................

DOB: ……/…………/…………   Age: ………………

Address..................................................................................................................

......................................................................................postcode: ........................

Tel:............................................

Next of Kin/Who to contact in an emergency:

Name: ........................................................... Relation to you:....................................

Contact number:.......................................................

General Practitioner:

Name:..........................................Surgery details: .........................................

Address: ......................................................................................................

Tel:.....................................................

Medical Conditions

Medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ALLERGIES:............................................

 

If you have any specific medical conditions that are being treated at a particular hospital, please add the relevant information in the notes section.

If there is anything you wish to tell us about that may be relevant to your treatment, please feel free to add it in the notes section.

If you care for someone, please let us know so that we can organise further support.

 

Notes About Me:

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