Hospital Discharge Scheme
1. Date referral made
2. Form completed by
3. Position/organisation
4. Contact number
5. Contact e-mail
6. Patient name
7. Patient address
8. Status:
Please select...
Owner
Occupier
Social Housing Tenant
Private Tenant
Other
9. What Borough or District Council does this address come under?
10. What Parish does this address come under?
11. Home telephone number
12. Mobile number
13. E-mail
14. Date of birth
15.
Details of relevant medical condition(s).
16. Does the patient have a designated contact who they are happy for us to contact regarding the support?
If no go to 23
Yes
No
17. Name
18. Relationship to patient
19.
Do you live with the patient?
20. Home telephone number
21. Mobile number
22. E-mail address
23. Planned discharge date
24. Access arrangements for property/key holder details
25. Is transport home from hospital required?
If no go to Q29
Yes
No
26. Please provide details including if patient has any disability or mobility needs such as walking frame, crutches, wheelchair.
27. Will the patient be able to transfer from car to home without assistance?
28. Any other information regarding transport needs
29. Does the patient require minor adaptions or alterations by the Handyperson service such as key-safe or handrails?
If no go to Q37
30. Is a keysafe needed?
If no go to Q31
Yes
No
If yes – preferred location and four digit combination to be set
(Do not use your year or date of birth, numbers 1 to 9, consecutive or repeated numbers)
31. Are grab rails needed inside the property? If no then go to Q32
Yes
No
If yes, please provide details of number, size and location(s)
32. Are grab rails needed outside the property? If no go to Q33
Yes
No
If yes, please provide details of number and location(s)
33. Is a staircase rail needed?
If no go to Q35
Yes
No
34. Does the handrail need to be straight or curved?
35. Other Handyperson service?
If no go to Q36
Yes
No
If yes, then please provide details.
36. Does the patient require moving or rearranging of furniture to accommodate specialist equipment?
Yes
No
If yes, please provide details including expected for delivery of equipment.
37. Does the patient require prescribed medication to be collected from the hospital pharmacy and delivered to them at home?
Yes
No
If yes, please confirm details including estimated time they will be available for collection
38. Does the patient have to pay for the prescription?
Yes
No
39. Patients GP surgery detail
40. Does the patient require a ‘home from hospital’ welfare package of Essential food supplies?
Yes
No
If yes, any dietary requirements?
41.
The patient has provided their consent to the sharing of their personal information by East Surrey Hospital and Tandridge District Council with other relevant third parties to enable the assistance requested under this referral to be provided.
Yes
42. Does the patient require on-going welfare support such as food delivery, prescription collection, telephone support?
43. Any other additional information
Contact Information