PERSONAL HISTORY FORM

Please print these instructions off prior to starting

• PLEASE CLICK ON EACH SECTION LISTED BELOW AND SAVE IT TO YOUR COMPUTER AS A 'DOWNLOAD'. IT IS A MICROSOFT 'WORD' DOCUMENT. WHEN YOU CLICK ON THE PAGE A BOX WILL APPEAR ASKING YOU IF YOU WISH TO 'SAVE' IT OR 'OPEN' IT. CLICK ON 'SAVE TO COMPUTER' AND SAVE ONTO YOUR DESKTOP. YOU CAN THEN OPEN THE PAGE AND PRINT IT OFF. IT IS 'WORD' DOCUMENT.
  
  
• CLICK ON ALL SECTIONS IN TURN UNTIL ALL THE SECTIONS HAVE BEEN SHOWN AND PRINTED OFF
  
  
• YOU SHOULD HAVE FIVE PAGES OF FORMS TO FILL IN (or SIX IF YOU HAVE ALSO PRINTED OFF THE DIY DETOX INFORMATION AND EIGHT IF YOU HAVE ALSO PRINTED OFF THE CONTRACT EXAMPLE)
  
  
• WHEN ALL THE SHEETS HAVE BEEN PRINTED OFF, FILL IN ALL THE REQUIRED SECTIONS COMPLETELY AND SEND THEM TO THE STAPLEFORD CLINIC
  
  
• WHEN YOU ARRIVE AT THE CLINIC FOR YOUR APPOINTMENT YOU WILL BE ASKED TO SIGN A PATIENT CONTRACT FORM. THIS FORM CAN BE SEEN ON THIS SITE BUT IT IS EASIER TO SIGN IT AT THE RECEPTION AT THE CLINIC WHEN YOU ARRIVE FOR YOUR APPOINTMENT
  
  
  • PERSONAL INFORMATION FORM
    PERSONAL INFORMATION NEEDED ABOUT YOU, SUCH AS YOUR FULL ADDRESS, WHO TO CONTACT IN AN EMERGENCY ETC
    
    
  • PERSONAL HISTORY FORM
    PERSONAL HISTORY, SUCH AS SCHOOLING, DRUG USE ETC
    
    
    
    
  • PATIENT TREATMENT CONTRACT
    A COPY OF THE PATIENT CONTRACT YOU WILL BE ASKED TO SIGN WHEN YOU ATTEND THE CLINIC FOR THE FIRST TIME. PLEASE PRINT OFF AND READ
    
    

PLEASE PRINT OFF EACH SECTION, COMPLETE FULLY, AND SEND TO

THE STAPLEFORD CENTRE
25A ECCLESTON STREET
LONDON
SW1W 9NP

If you have any difficulty with this form please contact the Stapleford Centre on 020 7823 6840 and the relevant forms will be sent to you.

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