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Silver Time Application Form
Please note that this application needs to validated and approved by a consultant.
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1.
First Name
(Required.)
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2.
Surname
(Required.)
3.
GHA Number (If known)
*
4.
DOB
(Required.)
Date / Time
Date
January
February
March
April
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June
July
August
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November
December
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Su
Sunday
Mo
Monday
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Tuesday
We
Wednesday
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Thursday
Fr
Friday
Sa
Saturday
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5.
Contact Details
(Required.)
Address Line 1
*
Address Line 2
Phone Number
*
*
6.
Email Address
(Required.)
*
7.
Medical Conditions (You will be eligible if you have one of the following conditions and are under the care of a GHA Consultant for them)
Please tick the boxes that are relevant:
(Required.)
You are pregnant and have significant heart disease, congenital or acquired.
Have lung cancer and are undergoing radical radiotherapy
Have cancer of the blood or bone marrow such as leukaemia, lymphonma or myeloma who are at any stage of treatment
If you are on immunosuppression therapies sufficient to significantly increase risk of infection
You have severe respiratory conditions including cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD).
If you have rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell).
Are having immunotherapy or other continuing antibody treatments for cancer
Are having targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors
Under going Chemotherapy due to Cancer
You have had a solid organ transplant (Lung, Kidney, Heart or Pancreas)
Have had bone marrow or stem cell transplants in the last 6 months, or who are still taking immunosuppression drugs
If you have another condition that you believe may make you particularly vulnerable and therefore eligible please enter the details below (creates new text box)
8.
Please enter the name(s) of the Consultant(s) who are responsible for you care if known.
Consultant Name 1
Consultant Name 2
Consultant Name 3
Consultant Name 4
*
9.
Please read the below
(Required.)
By filling in this form i consent the GHA to update my details and access my personal information.
THANK YOU FOR FILLING IN OUR QUESTIONNAIRE A MEMBER OF
OUR TEAM WILL CONTACT YOU SHORTLY.
For further Information or any queries and concerns please contact the PALS Department on:
PatientAdvice@gha.gi
+35020007022
