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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

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

    * I hereby confirm that I have read and accept the Privacy Statement

    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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