The Gables

Multi Activity Holiday Centre

PRIVATE AND CONFIDENTIAL

Client Profile Form

Name:_________________________      D.O.B:_______________     Age:________

Height:_______________     Weight:_______________

Present Address:  

   Doctor's Name:_________________________     Tel:_________________________

   Care Manager:_________________________     Tel:_________________________

       Key Worker:_________________________     Tel:_________________________

Guardians Name:_________________________     Tel:_________________________

Please give details of mobility levels and any disabilities.

Please provide details of ALL medication and the frequency they should be administered
(This information should also be provided if clients self administer their medication.)

Please provide details of any special dietary needs or food allergies.

Please provide a list of any activities you/your client does NOT wish to do.

Please provide any other information you feel may be relevant to you/your clients needs

I confirm that the information given on this form is true and complete.

I understand that if any of the enclosed details change I should inform Choice Care Services at the earliest opportunity before the commencement of the holiday.

I agree that if the details are incorrect, Choice Care Services, after consultation with the undersigned, may charge an additional fee to be invoiced at the end of the holiday.

Signed:_______________________      Name:_______________________      Date:___________

Designation: