|
/ News & Downloads / Downloads |
 |
|
Breakspear Hospital has many forms, information booklets, surveys, publications and other pdfs for people to download from our site. To save you navigating around the site to find the right page with the right form, we've put them altogether on this page.
If you have Adobe Reader, simply click on the desired forms and print out the full colour pdf.
Articles

Breakspear Hospital Trust
| |
Information leaflet
This leaflet provides information about Breakspear Hospital Trust such as who founded the Trust and what they hope to achieve. |
| |
Donation form
If you would like to support Breakspear Hospital Trust, please complete this form and return by post. |
Flu, travel and other vaccinations (including MMR)

General information
| |
Patient satisfaction questionnaire
A leaflet with a series of questions for the first time or regular patient of Breakspear Hospital which will help us provide you with better services. |
Guesthouse information
| |
Guesthouse information leaflet
An information leaflet about the Guesthouse available for patients attending Breakspear Hospital including the address, booking details and facilities available. |
| |
Guesthouse satisfaction survery
A leaflet with a series of questions for the first time or regular guests of the Guesthouse which will help us provide you with better service. |

New patient forms
There are 4 primary forms which must be completed before new adult patients meet their doctor.
The forms for adult patients are:
| |
Patient Record Card
This form provides the Hospital with the patient's name, address, next of kin and other required information. |
| |
Medical Questionnaire
This form is for the patient to complete and will give the doctor a clearer idea of the patient's specific symptoms and medical history. |
| |
Symptom Scoring Chart
This form is to grade the current symptoms. During on-going treatment, patients will be asked to complete this chart again, to monitor improvements. |
| |
Fee Consent form
This form is the payment contract between the patient and the Hospital. |
There are 4 forms for patients under 16 years of age which are:
| |
First Time Visit Child Consent Form
This form is to verify whether parents/guardians would like any test results or other information forwarded to the child's GP. |
| |
Patient Record Card
This form provides the Hospital with the child's name, address, next of kin and other required information. |
| |
Medical Questionnaire
This form is to be completed by the parents and patient to give the doctor a clearer idea of the patient's specific symptoms and medical history. |
| |
Fee Consent form
This form is the payment contract between the parent/guardian and the Hospital. |

Order forms
| |
Pathology Patient Order Form
This order form is so that patients of Breakspear physicians or Breakspear registered practitioners can order various pathology tests directly. Print out and fax the order to +44 (0) 1442 266 388. |
| |
Pathology Practitioner Order Form
This order form is so that Breakspear registered practitioners can order various pathology tests directly. Print out and fax the order to +44 (0) 1442 266 388. |
| |
Pharmacy order form
This order form
is so you can re-order all supplements prescribed for you during your stay and maintenance treatment after discharge.
Fax the order to +44 (0) 1442 266 388 or mail to the Hospital, attention "Pharmacy" or drop the form off at the Hospital. |
| |
Antigen vaccine order form
This order form is so you can re-order your tailor-made antigen vaccines. For instructions how to use this form, visit Instructions for re-ordering antigen vaccines. |

Treatment programmes
| |
CFS/ME Treatment Programme
An information booklet about the causes of CFS/ME, Breakspear Hospital's treatment approach and the commonly recommended tests, supplements and treatments for CFS/ME. |
| |
Chelation Therapy
An information booklet on Breakspear's chelation therapy and provides general information about which conditions chelation might help and about sources and absorption of heavy metals. |
| |
Child vaccinations and milk or egg sensitivity
An information booklet to help parents of children with a suspected milk or egg sensitivity determine if they should be concerned about administering various childhood vaccines. |
| |
Rehabilitation Programme (greyscale)
An information booklet about Breakspear's approach to alcohol and other addictions and our treatment programme. |
| |
Whole-body hyperthermia treatment (greyscale)
An information booklet on our hyperthermia infrared-A bed called the IRATHERM®1000, often recommend for detoxification programmes. |
| |
Weight-loss Programme
An information booklet on Breakspear's approach to weight loss, which includes help to fight the cravings and access to metabolism boosting equipment. |
| |
Time for a cervical health screen?
An information leaflet about why it is important to have regular screenings and telling about the at-hospital and at-home kit available for detecting HPV. |

|
|