INTERPRETATION REQUEST FORM by llf87114

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                                INTERPRETATION REQUEST FORM
   Please fax the FULLY COMPLETED form to ITS office on: 66617 (Internal) – 276 6617 (External)
                     (PLEASE COMPLETE ALL BOXES IN BLOCK CAPITALS)
                                    (ONLY ONE APPOINTMENT PER REQUEST FORM)

PATIENT NAME:                                                 HOSPITAL NUMBER: _____________________________

DATE REQUIRED: _____/_____/_____ TIME REQUIRED:                           _____          DURATION: ___________________

HOSPITAL: ______________________ DEPT/WARD/CLINIC: _________________________________________

PURPOSE/OTHER USEFUL DETAILS: _____________ ______________________________________________
Please Indicate: Home Visit / Consent / Discharge / Surgery / Procedure / Delivering Bad News / Sensitive Issue

CONTACT NAME/JOB TITLE: ___________________________________________________________________

CONTACT NUMBER: _______________________________ FAX NUMBER: ___________________________

EMAIL ADDRESS: _____________________________________________________________________________

Date Requested: ___ / ___ / ___ Tick if you want fax / email confirmation (Advance bookings only, i.e. more than 24 hours) 

You must inform our office of all CANCELLED appointments immediately, or your division may be charged.

COST CODE/CENTRE: __ __ __ __ __ __ / __ __ __ __ __ __ (ESSENTIAL)

INTERPRETER GENDER : (Please tick box) Female  Male  Either 
LANGUAGE REQUIRED: (Please tick box)                   (If subsequent booking - name of preferred interpreter: ______________________)

  Arabic              Bengali              Cantonese           Czech                      Farsi                 French

  Gujarati            Kurdish(Sorani)      Lingala             Mandarin                   Polish                Portuguese

  Punjabi             Romanian             Somali              Tigrini                    Urdu                  B.S.L (British Sign Language)

Other (Please Specify) _________________________________________
----------------------------------------------------------------------------------------------------------------------------------
                           CONFIRMATION OF BOOKING (Office Use Only)

Job Number: ________________________________________     Interpretation & Translation Service
                                                         Languages Unlimited
Name of Interpreter: __________________________________  M-Four Translations (City Council)
                                                         Chinese Health Information Centre
(Please complete in BLOCK CAPITALS)                      Communication Support Service
                                                         R.N.I.D.
         The booking office is open 9am to 4.30pm Monday to Friday only. For help or advice please ring 0161 276 6202
  For out of office hours emergencies only, please contact: Languages Unlimited –Telephone: 0161 773 0110.

								
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