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Changes to Cheltenham A&E during BMA Industrial Action 17 - 22 December

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Gloucestershire Home Blood Pressure Monitoring User Agreement

We are introducing blood pressure self-monitoring for those of you who would benefit, as agreed by your consultant. Please fill in this user agreement

Your name *

Your home postcode *

Your usual mode of transport to hospital appointments *

Car

Walk

Bus

Taxi

Bicycle

Van

Other

Your usual mode of transport to community midwife appointments *

Car

Walk

Bus

Taxi

Bicycle

Van

Other

If you travel by car or van, what type of fuel does it use? *

Diesel

Petrol

Electric (EV)

Hybrid

Not Applicable

6. Do you consent to Home Blood Pressure Monitoring (HBPM)? *

Yes

No

Do you understand how to upload your readings and when? *

Yes

No

Do you understand when to contact the hospital? *

Yes

No

Do you agree to return the BP machine to the hospital? Please bring it in with you in your hospital bag, or if birthing at home, please give it to the midwife that attends. *

Yes

No

*

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