Pre Admission Form | Perry Clayman Project PCP Rehabs

Name*

First Last

Gender*

Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Date of Birth*

Email*

Phone*

GP Surgery*

(we will not contact your GP without your signed consent to do so)

GP Surgery Location*

Your Next of Kin

Full Name (Next of Kin)*

Relationship to You*

Phone*

Email*

Consent*

I consent to PCP contacting my next of kin prior to treatment.

Admission Information

Date of proposed admission to PCP?*

Duration of stay?

PCP rehab location?*

What is your problem substance?*

DATA PROTECTION ACT 1998: IMPORTANT INFORMATION

PCP will create and maintain computer and paper records relating to you, prior to, during and after you leave treatment; these records will be processed in compliance with the Data Protection Act 1998. Please indicate your acceptance that by ticking this box you fully understand that you are providing consent that the information in these records may be shared both internally within PCP and to external organisations working with PCP in providing treatment; including but not limited to information technology service providers.*

I understand, agree and accept this data policy.

I fully acknowledge that I have read, understood and agree to PCP's Terms and Conditions of business, service information guide and treatment contract.*

I fully agree to the terms and conditions of business, service information guide and treatment agreement.

Treatment Agreement

Service Info Luton

Service Info Chelmsford