Applying to join the visitors list

Application to join the visitors list

Please complete the following form to apply to join the approved social/family visitors list at Rampton Hospital. Please read the Hospital's Carers Information Pack (which can be found on the Carers' information page of this site) before filling out your application.

If you are unsure at this time of when your first visit will take place you should still submit this form. When a date is known you should then email RamptonVisitorsCentre@nottshc.nhs.uk or telephone 01777 248321, to inform the Hospital of your intention to make a planned visit. Not booking could result in the visit not being allowed to take place.

At the time of your first visit, photographic identification and address confirmation (passport, photo driving licence, or other official photo identification) will be required along with biometric fingerprint readings before entry is permitted. Additional proof of address (utility bill, rent book, bank statement) will be required if your photo ID does not hold that information.

Please note: We cannot currently guarantee the security of this form whilst it is transmitted over the internet.

The information you provide on this form will be retained on a database.

Patient and applicant details

Note: Questions marked by * are mandatory

Details of patient to be visited

*This is a mandatory field. Name:

*This is a mandatory field. Ward:

Your details

*This is a mandatory field. Surname:

*This is a mandatory field. Forename/s:

*This is a mandatory field. Date of birth:

*This is a mandatory field. Address:

*This is a mandatory field. Postcode:

*This is a mandatory field. Telephone number:

*This is a mandatory field. Proposed date of first visit:

*This is a mandatory field. Relationship to patient, eg friend/mother/partner, etc:

Please advise us of any special needs that you wish for us to take into account when preparing for your visit (e.g. wheelchairs):

*This is a mandatory field. I declare that I have read the Carers Information Pack, that the information provided by me above is accurate and that whilst a visitor in this Hospital I will abide by all Hospital procedures and practices relating to visitors.

Confirm

TO BE COMPLETED BY HOSPITAL STAFF

Visitor Reference No.:

Type of photo ID produced:

Photo checked:

Ward:

Patient Hospital No.:

Address checked against printed address on ID:

Fingerprint reading obtained:

Date form submitted:

Form completed by:

* Spam Guard: Is a fire hot or cold?

Applying to join the visitors list

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Application to join the visitors list

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