Online Application for Care Services

Boxes with an asterisk * next to them are required items

Step 1
personal details

pick your house & care service

nightingale house

hammerson house

*

pick your house & care service

*
*
*
*
*
*
*
Step 2
next of kin

main contact person

*

add next of kin

delete next of kin

add next of kin

delete next of kin

Step 3
financial circumstances

property

Owner

Tenant

Yes

No

Own home

Care home

Hospital

Other

£

Yes

No

Yes

No

Yes

No

Yes

No

Step 4
financial circumstances

pensions / benefits / other income / savings

Weekly Income

£
£
£
£
£

Savings and income after tax

Total savingsAnnual income

£
£
£
£
£
£
£
£
£
£
£
£
£
£

conditons of entry

Admission is subject to a medical assessment and adherence to financial policies described in attached documentation. The home cannot undertake to accomodate any applicant in any specific section of the Home and reserves the right to transfer at their sole discretion, a resident to any section of the Home.

I hereby declare that I understand and agree to the above conditions of entry and the statements I have made are true.

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