Carelaw: FREE NURSING CARE ASSESSMENT

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The UK's Healthcare Law Service

0870 2412139
rob@carelaw.co.uk

FREE NURSING CARE ASSESSMENT

Please complete the following form as completely as possible, and click the 'Submit' button to send the form to us. Doing so places you under absolutely NO OBLIGATION following the assessment. Information you share with us will be kept confidential and not disclosed to anyone else without your permission. We are registered under the Data Protection Act 1998 and our conduct is regulated by the Solicitors Regulation Authority.

SECTION 1 - Your Details
Your Name:
Your date of birth:		for security purposes.
Your Address::
Telephone / Mobile:
Email address:
I am The:		Son Daughter Wife Other (Select one) of
		An NHS patient about to be discharged into a private nursing home at own cost; OR:
		An NHS patient who was discharged into a private nursing home at own cost; In either case: Actual or anticipated discharge date:

SECTION 2 - Patient Details
Name of Patient:
Patient date of birth:		If Deceased, date of death

Power of Attorney:		Do not hold Power of Attorney Hold Power of Attorney/Deputyship or Receivership
Address of Patient:

SECTION 3 - Symptoms / Diagnosis

General description of patient's condition

Please describe briefly the patient’s condition, problems encountered in the past few years and any diagnosis.

Please select each of these items that (in your view) best describes the patient’s condition/needs:

Need/Symptom

Low/None

Moderate

Severe


Physical Diseases
Mental state
Mobility
Feeding
Continence


C.
MENTAL HEALTH ACT Has the patient ever been subject to detention under The Mental Health Act 1983?. If so, please give details:		No Yes (Pleas give details below) Details:


SECTION 4 - Steps taken to obtain continuing care funding
Here describe briefly what has been done and the current outcome:


SECTION 5 - Trust responsible for care
Name and address of Trust responsible for the patients care (if known):


SECTION 6 - Any other relevant information
Approximate financial losses (Care fees) £?:
Please tell us anything else of relevance. For example has the patient’s condition recently worsened? Is there an outstanding complaint to the Ombudsman?:

SECTION 7 - Market Research etc.

Please tell us where you heard about this web site:

We try to keep our clients informed as to developments in areas of interest to them. Unless you check this box we will assume you wish to be included when we send out these up-dates.

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	Robert Campbell & Co., Greenhills, Winsham, Braunton EX33 2LX Regulated by the Solicitors Regulation Authority. SRA No. 00327671
©	web content copyright © Robert Campbell 2010
©	web design and code © 56kb.com 2010

Back to the top

	Robert Campbell & Co., Greenhills, Winsham, Braunton EX33 2LX Regulated by the Solicitors Regulation Authority. SRA No. 00327671
©	web content copyright © Robert Campbell 2010
©	web design and code © 56kb.com 2010