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ABOUT US

HOLIDAY ACCOMMODATION

DIALYSIS FACILITIES

EMSWORTH

Payment for holidays

FUNDRAISING

HOLIDAY BOOKING FORM

WAYS OF GIVING

GIFT AID DECLARATION

Fund raising at St Anne's

Links for Charing Cross Holiday Dialysis Trust

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Guestbook

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CXHDT HOLIDAY BOOKING FORM

St Anne's,34 Havant Road,Emsworth, Hampshire PO10 7JG
Tel 01243 376541 (Mon-Fri 9am-5pm only)Fax 01243 372807 email:e.faber123@tiscali.co.uk
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PATIENT'S DETAILS (to whom all correspondence will be sent)

Name:______________________________Date of Birth___________

Address__________________________________________________

_________________________________________________________

Post Code ____________________ Tel No. ______________________

Next of kin (Name) _________________________________________

Relationship ___________________Tel No. _____________________

Address _________________________________________________

DIALYSIS DETAILS
Main Dialysis Unit where you dialyse

W London Treatment Centre (Name of your dialysis unit) ________________________

Other patients (Name of your dialysis unit)________________________________________

Dialysis days (Please tick) Mon Tues Wed Thurs Fri
Treatment (Please tick) Haemodialysis CAPD Home choice Transplant

NAMES OF ALL PERSONS STAYING (Please specify age if under 19)
Full Name:
_________________________PATIENT_________________________

________________________________________________________

________________________________________________________

________________________________________________________

________________________________________________________

______________________________________________________________
HOLIDAY DATES:
From Saturday _____/____/_____to Saturday______/_______/_______ _
Additional night___________________________________________________
Short Stays (Subject to availaility)

__________________________________________________________
ACCOMMODATION REQUIREMENTS: (number of rooms required)
Double Bedroom [ ] Twin bedded Room [ ] Single Bedroom [ ] Cot [ ]
No accommodation required - Dialysis Only [ ]
If you have any special requirements please specify

________________________________________________________________
Wheelchair Required [ ] Difficulty with stairs [ ]










TERMS AND CONDITIONS

Residency - There is a resident House Manager who will greet you upon arrival. Please do not arrive before 12 noon on your appointed day and on your last day you are asked to vacate your bedrooms by 9.30a.m. You may use the lounge and kitchen until 10.30a.m.

Accommodation - St. Anne's provides self catering holiday accommodation for up to three families at a time, each family having their own bedroom(s), bathroom, lounge and kitchen. The sun lounge, swimming pool and garden are shared with other occupants of the house and non residents using the dialysis facilities. There is a pay telephone for your use in the hall.

Dialysis - There is a resident renal nurse who will contact you during the week before your holiday to finalise dialysis arrangements.

CAPD - Your unit should arrange delivery of fluids to arrive the week before your holiday. Please check that this has been arranged.

Haemodialysis takes place in a purpose built dialysis unit in the garden and accommodates 3 patients at any one time using Gambro AK 90 machines.

Provisional Bookings - Provisional bookings can be made by phone,Monday to Friday 9am to 5pm but are only confirmed if a completed Booking Form and the booking deposit of £25.00 are received within seven days.

Booking Details - Only persons whose names appear on the Booking Form may stay. There can be no substitution of names without prior written notification. You must check your confirmation details carefully as soon as you receive them and advise us immediately if anything appears incorrect. Later amendments may not be possible. If you have not received your confirmation letter within 14 days please contact St Anne's.

Booking Fee - A £25.00 booking fee is required with this Booking Form. This will be returnable on arrival, or if there is a medical reason for cancellation, but withheld to cover costs for unreasonable cancellations.

Cancellation - If it is necessary to cancel your holiday this must be done in writing by the person who signed the Booking Form or your consultant if there is a medical reason.

General - Please bring any medication you are taking with you. Towels and bedding are provided but you will need to bring tea-towels and washing-up liquid for your kitchen needs. Please bring your own towels for use at the swimming pool.

Pets - We regret that we cannot accommodate any pets on the premises.

Valuables - The Trust cannot accept responsibility for any valuables or personal possessions.

Fire Safety - We must have the names of ALL persons resident at St. Anne's (including children). Please sign the Register on arrival.





Invoice - This will sent shortly after your booking has been confirmed and full payment must be received by the Treasurer no later than 4 weeks prior to the commencement of your holiday

The Trust reserves the right at its absolute discretion to cancel or curtail holidays or refuse admission to the property.

PLEASE RESPECT THE PRIVACY AND COMFORT OF OTHER GUESTS AND ABIDE BY THE SAFETY REGULATIONS AND HOUSE RULES DISPLAYED IN YOUR ROOMS






______________________________________________________
Charges for accommodation
For patients whose main Dialysis Unit is West London Treatment Centre
Patient,immediate next of kin and their own children under 19 there is no charge



1. Extended family and friends of above,and



2. Non West London Centre Treatment Centre Patients


Adult(s)_______________@£120.00 per week

Additional single nights___@£20.00 per person
Children under 5 ________ Free of charge
Children 5-19________ £50 per week or £8 per night

Booking fee_____________£25.00



TOTAL DUE_____________£
_____________________________________________________________

I agree to the above conditions





Signed................................................Date..................................





Please return this form,together with your booking fee,to:




Mrs E Faber, Charing Cross Holiday Dialysis Trust,St Anne's, 34 Havant Road,Emsworth Hants PO10 7JG
Tel/fax: 01243 372807
Cheques to be made payable to:
Charing Cross Holiday Dialysis Trust
____________________________________________________________
For official use only
Date rec'd_______Ackd_____Confirmed___Invoiced____Amount_______















































































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ABOUT US |HOLIDAY ACCOMMODATION |DIALYSIS FACILITIES |EMSWORTH |Payment for holidays |FUNDRAISING |HOLIDAY BOOKING FORM |WAYS OF GIVING |GIFT AID DECLARATION |Fund raising at St Anne's |Links for Charing Cross Holiday Dialysis Trust |Message Board |Guestbook |Mail Form