DoLS Form 1

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Information

Type of Request * This field is required

Request a Standard Authorisation only

Request an Urgent and Standard Authorisation

Relevant Medical History * This field is required

Sensory Loss * This field is required

Communication Requirements * This field is required

Name and address of the care home or hospital requesting this authorisation * This field is required

Name of the Supervisory Body where this form is being sent * This field is required

How the care is funded * This field is required

Local Authority

NHS

Self-funded by person

Local Authority and NHS (jointly funded)

Funded through insurance or other

CQC number * This field is required

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