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Client Registration Form

Client Registration form

Your Details

Title *

First Name *

Last Name *

Address *

Postcode *

Tel no * (with code)

Mobile no *

Fax no

Email *
(If you do not have an email address, or do not know your address then please use clients@origincare.com)

Sex * MaleFemale

Date of Birth *

Nationality *

Level of Spinal Injury *

Year of Injury *

Your Height *

Your Weight *

Do you work? * Full TimePart TimeDon't work

Do you live alone? * YesNo

Funding

Is your funding from/by:Social servicesPrivateNHSDirect PaymentsOther (please give details)

Personal care assistance requirements

Which sort of live-in option do you require? *Respite Carer(s) (normally for short-term cover and holiday but can be an ongoing series)Private permanent carer(s) (introduction of carers to be employed by you)Fully Managed Care (long-term cover involving all carers, permanent & respite, employed by us to work on your behalf)

If you know the dates you need a carer please enter them below. If you do not have specific dates, please leave blank.

Start Date

End Date

Do you need your assistant to drive?EssentialPreferableNo

For which of these tasks do you need assistance?Getting upGoing to bedWashingDressingFeedingShavingCookingCleaningShopping

Bladder ManagementCondom with leg bagIn-dwelling catheterSupra-pubic catheterNeed for expressionOther

Is bowel/bladder management carried out by:Your CarerA District nurseOther

Bowel ManagementSuppositoriesDigital stimulation/check that bowel is emptyEnemaOther

Routine of bowel evacuation

e.g. daily/two daily

Carried out by: CarerDistrict NurseOther

Do you use BedShower chair/toilet

Personal Hygiene

Which method of washing do you use? ShoweringBedbathBathing

How often

Do you require turning at night? YesNo

Moving/Handling

Do you use: HoistStanding transferSliding boardOther

Do you suffer from / are you prone to: PainAutonomic dysreflexiaSpasmSevere coldLow blood pressureSkin problems

Do you use a ventilator YesNo

Do you want your carer to be

Please pick * Male (Prefer)Male (Essential)Female (Prefer)Female (Essential)Don't mind

Medical conditions

Other than the spinal injury itself, do you have/have you ever had any other illnesses or medical conditions? YesNo

Additional information

Anything which may affect your choice of carer (e.g. if you have pets) or any forthcoming holidays.

Declaration of correct information

(Please Tick) * I hereby confirm that to the best of my knowledge, the above statements are true and correct

Origin PAs and client’s rate Origin training as excellent:

‘The training was the best I’ve ever had. It covered everything that’s important to the people we work with.’

‘Staff are trained to a high standard.’

‘The training must be excellent because the care is good.’

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