Priors Mead - Out-of-Home Visits
Prior to collecting a Resident for any Out-of-Home Visit, please complete this form and confirm the time of collection and return with the home. Where a visit is deferred, please resubmit this form.

Once you click 'Submit' your response will automatically be sent to the home.
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Email *
Nominated Visitor's Name *
I.E. one of the resident's two named visitors who will be hosting the Out-of-Home Visit.
Your Mobile Phone Number *
Please make sure you have this phone with you for any visits.
Your Home Phone number *
Resident's Name *
Please give the name of the resident you will be visiting.
Address of Out-of-Home Visit *
Where will the Out-of-Home Visit take place.
Date for Visit *
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Planned Collection Time *
Time
:
Planned Return Time *
Time
:
Vaccination Status *
No Vaccine
First Vaccine
Second Vaccine
Nominated Visitor
Out-of-Home Visit Guidelines
Please ensure masks are worn when in a car or if the resident needs assistance visiting the toilet.

The resident should remain outside at all times, save when they require the use of a toilet.

The only people present should be the resident, the nominated visitor and a carer, if attending.

If the weather changes or other factors make it unsafe for the resident to remain outdoors, please bring them back to the care home rather than take them into your own home.

When planning the visit, please bear in mind that unvaccinated people are a greater risk to the resident than those who have been vaccinated.

Please ensure all current guidelines for this type of visit are followed.
Guidelines Declaration *
I confirm that I have read and understood the guidelines above, and will ensure they are followed.
Disclaimer *
I recognise that visiting any care home or taking residents out of a care home may lead to an increased risk of contracting Covid-19 or other infectious diseases. I confirm that the choice to conduct the Out-of-Home Visit is solely mine and I take full responsibility for any consequences that may follow this decision and, by ticking the 'I Agree' box below, hereby absolve Nightingales from all and any responsibility in this regard.
Data Protection Declaration *
In accordance with The Data Protection Act 2018 (DPA 2018), by ticking the 'I Agree' box and submitting this form, I give permission for all or part of this data to be held on both computerised and manual records, which I may request access to.
Date Form Submitted *
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Version
vPM.4.0.D - 03.05.2021
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