St Anne's,34 Havant Road,Emsworth, Hampshire PO10 7JGTel 01243 376541 (Mon-Fri 9am-5pm only)Fax 01243 372807 email:e.faber123@tiscali.co.uk___________________________________________________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 [ ]