ens1nq~

OSPI'FAL

ADMISSION FOR
Please complete and return to the hospital seven days prior to admission.

Surname B~rnq_~ First name(s) S~ tAX~~

Preferred Na~ ~\"C~ Male /Female

Date of birth \,, I _t) It I;, i4 Age Ethniclty

Postcode l O l ~;.t
Address
(w.tQ.n ~tYU:\
Postal Address \0 \ 03
Business Mobile
Phone Number Home

Email Address YourtamllvDoctor df". L,,~ ~'1,t<~

Next of Kin / Contacts

1) Contact Person \)~Vl \'o-- \l~ [\/\,"., • <;'1c:r.,..-C-<\ Relation~hlp ft<&t ~\l,.:,~ /IJFsr- fh , a •
Address A\£\..-~
Phone Number Home
f\o • \ t" J~a& i- fSo.t H ~ , f'\ar~b.t'J
BusineH
Num~r where staying
whilst vou are In hospital

Mobile l4to)~& -3~36

Relatlonshlp
2l conact Pff'son
Number where 5ta1tin9
Address whilst you are 11, hospttal

Business Mobile
Phone Number Home

Health Information Privacy Explanation

tea pate t to
Under the provisions of the Health nformatJon Privacy Code 1994 there s a requirement to collect and to e Info ma
help provide good and safe treatment. It s mandatory to send certain health Information to othe o gan at on f Health
Your medical records wlU be kept secure and wlU only be accessed by authorised per onneL You a a pat nt. h
nolt!$for as Ions as Kensington Hosp tal stores them. During this time, if you de re, you can update o rre t V ts
or 11«e5s to your notes shouk:I be made through our Privacy Officer
On the day of your operation until you are able to rece ve phone calls our reception or nurs ng tart w1 a gene a
totatement regarding your health, unless advised otherwise
•you do not wi.h to have any Information dlecloNd ■ bout your st■y- ple■H Inform us on ■dmlaion,
'If for ny reason you re quirt! to be transferred to another hospital a copy of you notes from Ken nst
~aldi nformadon P 81;,'J Code s avatlable for further nformatlon If de I ed