Age UK Maidstone, Sevenoaks and Tonbridge referral form

Referred By

Client's Title

Client's First Name

Client's Surname

Client's Marital Status

Client's Gender

Client's Date of Birth

Client's Telephone Number

Can we contact the client direct? Yes No

If no, please provide name, relation type and telephone number for preferred contact

Client's Full Address

Lives with

Accommodation type: Private Owned Private Rented Housing Trust Council

Please check to indicate if the client has the following Life line/Personal Alarm Key Safe

Doctors Surgery

Please list all medication taken by client

Client's Medical History

Please inform us of any allergies or dietary requirements:

The Client's Speech Good Average Poor

The Client's Hearing Is... Good Average Poor

The Client's Sight Is... Good Average Poor

Does the client experience memory loss? Yes No

How is the client's mobility? Good Average Poor

If the client has any walking aids, please list them below:

Please provide name, relation type and contact details for the client's emergency contact or Next of Kin

Which service(s) are you referring for? Foot Care Day Care Dementia Day Care Bathing ILS COGS Club

Day Care Only - Does the client require transport at an additional cost? Yes No

Bathing Only - Bathing Requirements: Getting into water Drying Dressing

Foot Care Only - Please indicate whether any of the following are applicable Diabetic Taking Steroids Taking Anticoagulants Has - or has ever had - ulcers on legs or feet Receiving chiropody at time of referral

Foot Care Only - Which clinic does the client wish to be seen at?

If there is anything else we should be aware of, please use the space below:

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