SOUTH EAST COAST AMBULANCE SERVICE NHS FOUNDATION TRUST DEFIBRILLATOR REGISTRATION FORM – Site Name: Site Address: Site Contact & Position: Site Telephone: Mobile: Site Email: Precise location of defibrillator within site: Name of person responsible for checking AED and email address Mon Fri: – 24/7: Other: 0900 1700 – AED Availability (Tick relevant box): Extra Info (if other): KEYPAD CODE TO OPEN CABINET if applicable Do you want someone to collect the AED from you? YES/NO In the event of a call: Are you willing to take the AED to the patient? YES/NO AED Manufacturer: AED MODEL: Serial No: Main Electrode pads: Electrode Pads Expiry date: Spare Electrode pads: Battery Expiry Date AED installed: Date We are occasionally to share PAD site locations and Freedom of Information availability with members of the public - can you confirm you YES/NO Requests are happy for us to include your site details? Other Comments Please complete and email to or post to: FAO Shirley Power, Voluntary Services, South East Coast Ambulance Service, The Horseshoe, Banstead SM7 2AS
SOUTH EAST COAST AMBULANCE SERVICE NHS FOUNDATION TRUST DEFIBRILLATOR – REGISTRATION FORM Site Name: Site Address: Site Contact & Position: Site Telephone: Mobile: Site Email: Precise location of defibrillator within site: Name of person responsible for checking AED and email address AED Availability (Tick relevant box): 24/7: Mon – Fri: 0900 – 1700 Other: Extra Info (if other): KEYPAD CODE TO OPEN CABINET if applicable In the event of a call: Do you want someone to collect the AED from you? YES/NO Are you willing to take the AED to the patient? YES/NO AED Manufacturer: AED MODEL: Serial No: Electrode Pads Expiry date: Main Electrode pads: Spare Electrode pads: Date AED installed: Battery Expiry Date Freedom of Information Requests We are occasionally to share PAD site locations and availability with members of the public - can you confirm you are happy for us to include your site details? YES/NO Other Comments Please complete and email to or post to: FAO Shirley Power, Voluntary Services, South East Coast Ambulance Service, The Horseshoe, Banstead SM7 2AS
SECAMB%20DEFIB%20REGISTRATION%20FORM.docx