Transfer on Medical Grounds

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You will need to complete the form below and provide written evidence from your doctor to be eligible for a medical assessment.

Transfer Medical Assessment Form

Note: Questions marked by * are mandatory

All data sent via this form will be used solely for the purpose of medical transfers.

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*This is a mandatory field. Full Name:

*This is a mandatory field. Date of Birth:

*This is a mandatory field. Address:

*This is a mandatory field. Telephone:

*This is a mandatory field. Email:

Preferred Contact Method:

*This is a mandatory field. Do you live in a; house, flat, maisonette or other? (Please specify)

*This is a mandatory field. How many bedrooms in your property?

*This is a mandatory field. List all who live with you permanently. (Please include: full name, DOB and relationship to you)

*This is a mandatory field. Please describe the illness, disability or medical problem. Who does this affect?

*This is a mandatory field. Can you move about on the level? (Tick where applicable)

Without help
Using a walking aid
Wheelchair
Not at all

*This is a mandatory field. Can you climb a flight of stairs?

Without help
Using a walking aid
Not at all

*This is a mandatory field. Are there any stairs in your property? If so, how many inside and outside your property?

*This is a mandatory field. Is an occupational therapy referral necessary at the property?

Yes
No

*This is a mandatory field. Are you applying for a transfer to receive support/care from relatives or friends? If so, please describe.

*This is a mandatory field. Please provide details of why you want to move:

*This is a mandatory field. General Practioner Details (please include name, address and contact number):

*This is a mandatory field. Do you attend a hospital/clinic?

Yes
No

Name(s) of hospital or clinic:

Name(s) of consultants:

*This is a mandatory field. Please list any medication or treatments you are currently prescribed:

*This is a mandatory field. Please tick the box if you confirm that the information on this form and the following statements are true. You hereby give permission for this info to be forwarded to the SBHA Medical Assessor. The medical assessor has your permission to contact your GP, clinician, and/or hospital consultant if necessary.

Yes, I confirm

*This is a mandatory field. Today's Date:

*This is a mandatory field. Please upload relevant evidence from your doctor here.

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Formerly SBHA, but now The Guinness Partnership, We were founded in 1890 to improve people’s lives and create possibilities for them.

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