Silver Time Application Form

Please note that this application needs to validated and approved by a consultant.

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* 1. First Name

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* 2. Surname

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* 3. GHA Number (If known)

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* 4. DOB

Date / Time

Date

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* 5. Contact Details

Address Line 1 *

Address Line 2

Phone Number *

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* 6. Email Address

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* 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:

Have cancer of the blood or bone marrow such as leukaemia, lymphonma or myeloma who are at any stage of treatment

You have had a solid organ transplant (Lung, Kidney, Heart or Pancreas)

You have severe respiratory conditions including cystic fibrosis, severe asthma and severe chronic obstructive pulmonary disease (COPD).

Under going Chemotherapy due to Cancer

Are having targeted cancer treatments which can affect the immune system, such as protein kinase inhibitors or PARP inhibitors

If you are on immunosuppression therapies sufficient to significantly increase risk of infection

Have lung cancer and are undergoing radical radiotherapy

You are pregnant and have significant heart disease, congenital or acquired.

Are having immunotherapy or other continuing antibody treatments for cancer

If you have rare diseases that significantly increase the risk of infections (such as severe combined immunodeficiency (SCID), homozygous sickle cell).

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)

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* 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

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* 9. Please read the below

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

Silver Time Application Form

Question Title

* 1. First Name

Question Title

* 2. Surname

Question Title

* 3. GHA Number (If known)

Question Title

* 4. DOB

Question Title

* 5. Contact Details

Question Title

* 6. Email Address

Question Title

* 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:

Question Title

* 8. Please enter the name(s) of the Consultant(s) who are responsible for you care if known.

Question Title

* 9. Please read the below

* 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: