Questionnaire

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Contact

Free Initial Enquiry

Please complete this short form to assist us in evaluating potential eligibility for NHS Continuing Healthcare:

Your Name *

First

Last

* Indicates required field

Your Email *

Your Phone Number *

Please leave your phone number if you would like to be contacted by phone

Please indicate how you would prefer to be contacted *

Email Phone WhatsApp Text

What is your relationship to the patient? *

Please select from the drop down menu

If 'other' please state: *

Do you hold Lasting Power of Attorney or a Deputyship Order for the patient? *

Yes No Other

If 'other' please explain below: *

Does the patient have difficulty with or require help with any of the following? *

Breathing Eating Toileting Skin integrity e.g. pressure sores Mobility Communication Psychological and Emotional Needs Cognition e.g. dementia Challenging behaviour e.g. aggression or resisting care Managing pain and taking medication Dizziness, blackouts, mini strokes Other (please describe below)

Please select all that apply

If 'other' please describe: *

Does the patient require 24-hour care? *

Yes No

Where is the patient currently being cared for? *

In residential care In hospital At home In hospice care Other

If 'other' please state: *

If you wish, please provide a brief summary of the patient’s health needs and the care required to address them: *

The data I submit will be collected and processed in accordance with ARROW’s Privacy policy. I understand that it will not be used for any purposes other than those specified. *

Yes

Submit

ARROW Continuing Healthcare Consultants
Proprietor: Dr Ros Setterfield: PhD in Law; PGDip (Legal Studies); BA (Hons)

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About Us
- Testimonials
Our Services
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Contact