The Brooke Surgery EQUIPMENT LOAN AGREEMENT This Agreement Is

the brooke surgery equipment loan agreement this agreement is made between: «patient_title» «patient_forename1» «patient_surname»

The Brooke Surgery
EQUIPMENT LOAN AGREEMENT
This agreement is made between:
«PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname»
«PATIENT_House»
«PATIENT_Road»
«PATIENT_Locality»
«PATIENT_Town»
«PATIENT_County»
«PATIENT_Postcode»
Date of Birth: «PATIENT_Date_of_Birth»
NHS Number: «PATIENT_Current_NHS_Number»
«PATIENT_Main_Comm_No»
«PATIENT_Alt_Comm_No»
«PATIENT_Mobile_No»
And
The Brooke Surgery, 20 Market Street, Hyde, Cheshire SK14 1AT
For the loan of the equipment listed below
Equipment
Machine Number
Period
Blood Pressure Machine
1 2 3 4 5
9 Days or 7 Days’ worth of recording
Date Issued
Date Returned
Date: «SYSTEM_Date»
Terms and Conditions
====================
*
The equipment is supplied for the maximum period detailed above
and is due to be returned on or before the date specified. The
equipment is to be used only for the specific use of the patient
named above.
*
The Practice will keep the equipment in good condition and repair
and will test that it is fully working and in good order prior to
issue. The patient, in accepting the equipment, warrants that they
have home or personal insurance in force to cover loss or damage
(including accidental damage) to the equipment both in the home
and elsewhere whilst under their control, on a “new for old”
basis.
*
The patient agrees that in the event of such loss or damage
arising they will immediately inform the Practice, and they will
make a claim on their policy and forward all proceeds of the claim
to the Practice for an agreed sum.
*
The patient agrees that where there is a shortfall between the
value of the settled claim and the cost of a direct or compatible
replacement item, the cost of the shortfall becomes their
responsibility and will reimburse the Practice accordingly.
*
The patient agrees that where the equipment is not returned by the
date above the deposit will be charged with a daily rental after
which time the full replacement value, or the return of the
equipment in full good order is due. Where this does not occur the
Practice reserves the right to take legal action to cover the
equipment or equivalent cost including the daily rental charge
accruing for each additional day outstanding.
*
The patient will not modify the equipment or attempt to open the
equipment, or use it in any way inconsistent with its purpose.
*
The patient is responsible for the return of the equipment by the
due date without reminder, and must obtain a signed receipt by a
staff member on their copy of this agreement as evidence that the
item has been returned. This remains the patient’s responsibility.
*
The term may be extended only by the written agreement of the
Practice in the form of a new agreement form covering the extended
period.
*
The Practice will instruct the patient on the correct use of the
equipment, however is not responsible for failure to use the
equipment correctly once it has left the premises.
Explained and Issued: …………………………………………………..… (Staff Member)
Print Name: ………………………………………………………………………
Date: «SYSTEM_Date»
Signed and Agreed: ………………………………………………………… (Patient)
Print Name: «PATIENT_Forename1» «PATIENT_Surname»
Date: «SYSTEM_Date»
Date Returned : ………………………………………………………………..
Received By: …………………………………………………………………….. (Staff Member)
Home Blood Pressure Monitoring Patient Instructions
===================================================
Thank you for collecting the Omron device for blood pressure
recording. Please ensure this is returned to The Brooke Surgery in 9
days time, ie after you have completed one weeks worth of readings.
Start collecting the results tomorrow and record the results on the
chart on the next page.
To help ensure a reliable reading, avoid eating, smoking, or
exercising for at least 30 minutes before taking a measurement. Remove
any tight-fitting clothing from your upper arm.
Please print the form below and complete as per the instructions
below.
1.
Sit on a chair with your feet flat on the floor and place your arm
on a table so that the arm cuff will be at the same level as your
heart.

2.
Apply the arm cuff to your upper arm. The coloured marker should
be centred on the inside of your arm and point down the inside of
the arm, so that the air tube runs down the inside of your forearm
and is in line with your middle finger.
3.
Secure the cuff around your arm using the fabric fastener strip,
ensure that your arm is supported by the table and completely
relaxed.
4.
Press the O/I START button, ensure that your are relaxed
When measurement is complete, the monitor displays your blood pressure
and pulse rate, and automatically deflates the cuff.

Top Figure Bottom Figure
Please contact the Surgery 5 working days after you have returned your
readings, if you have not been contacted. Your Doctor will have left a
message for you.
Patient Name: «PATIENT_Title» «PATIENT_Forename1» «PATIENT_Surname»
Patient DOB: «PATIENT_Date_of_Birth»
*
Take readings in the morning and in the evening
*
record two readings on each occasion, a minimum of one minute
apart
*
perform recordings for 7 days
*
Add the total of each row and record in the last 2 columns
*
Add the total of each of the last two columns
*
Date of the first day of recording started:
Day
Morning
Evening
Row Total Top
Row Total Bottom
1
Top figure
Top Figure
Top Figure
Top Figure
Bottom Figure
Bottom Figure
Bottom Figure
Bottom Figure
2
Top Figure
Top Figure
Top Figure
Top Figure
Bottom Figure
Bottom Figure
Bottom Figure
Bottom Figure
3
Top Figure
Top Figure
Top Figure
Top Figure
Bottom Figure
Bottom Figure
Bottom Figure
Bottom Figure
4
Top Figure
Top Figure
Top Figure
Top Figure
Bottom Figure
Bottom Figure
Bottom Figure
Bottom Figure
5
Top Figure
Top Figure
Top Figure
Top Figure
Bottom Figure
Bottom Figure
Bottom Figure
Bottom Figure
6
Top Figure
Top Figure
Top Figure
Top Figure
Bottom Figure
Bottom Figure
Bottom Figure
Bottom Figure
7
Top Figure
Top Figure
Top Figure
Top Figure
Bottom Figure
Bottom Figure
Bottom Figure
Bottom Figure
Total of row total top
Total S
Total of row total bottom
Total D
Frame2