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Telecare services request form
Are you applying for yourself or on behalf of someone else?
Myself
Someone else
If you are applying on behalf of someone else, would you like the correspondence to be sent to a different address? If yes, please tell us the correspondence details below
Yes
No
Correspondence / contact details (if different from customer details)
Contact name
Title
Title
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
First Name
Surname
Contact address
Address
Address 2
City/Town
Post Code
Home telephone number
Work telephone number
Mobile telephone number
Relationship to keyholder
Personal details
Name
Title
Title
- None -
Miss
Ms
Mr
Mrs
Dr
Other…
Enter other…
First Name
Surname
What name do you preferred to by called by?
Date of birth
Address
Address
Address 2
City/Town
Post Code
Contact phone number
Please give us the phone number you would like us to use to contact you
Does anyone else live in the house with you?
Yes
No
Sometimes
Please tell us the name(s) of who else lives in the house with you, and their relationship to you
Who is your phone provider?
Some telephone suppliers may not guarantee to support Telecare systems. If your supplier is not BT, please check with your supplier that they do support Telecare systems.
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Did you find what you were looking for?
Why wasn't this information helpful
Too much information
Not enough information to answer my question
This isn't what I was looking for
I tried this and it didn't solve the problem
I don't like this feature or policy
Other
Tell us more
Limit to 250 characters.
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