Contact us about Technology today

Technology Enquiry

If you would like more information or to apply for Home Safety Service Technology, please complete the form below and one of the TEC team will get back to you.

1. Are you applying for yourself or someone else?
2. *
3. 1. Please Provide:
  2. Your name
  3. Your contact telephone number
  4. Your email address
  5. Your relationship to the applicant
5. Applicant Details
6. Name*
7. Date of Birth (DD/MM/YYYY)*
9. Address
10. Your address
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  3. Your Address
    
    OSG Postcode Search (Custom drop-down list)
    
    Postcode
    
    Address
12. Contact Details
13. Landline Telephone Number*
14. Mobile Telephone Number
15. Email Address
17. GP Details
18. GP name
19. GP Surgery Address*
20. GP Contact Number*
22. Reason For Enquiry
23. Is this equipment to help with end of life care?*
  
  Yes
  
  No
24. Have you fallen in the last 12 months?*
  
  Yes
  
  No
25. If you answered "Yes" what was the outcome? (e.g hospitalisation)
26. Is the individual currently in hospital *
  
  Yes
  
  No
27. 2. Is technology essential for discharge
    
    Yes
    
    No
  3. What is the anticipated discharge date
  4. What type of technology are you requesting
28. Other (Please Specify)
30. Keyholder Details
31. We require contact details of at least one key holder. A key holder may be contacted at any time of the day or night by Careline to assist in an emergency or to relay important information regarding welfare or whereabouts.
  
  Keyholders may be family members, neighbours or friends and should ideally be able to attend (if required) within a recommended 45 minute maximum response time. Keyholder’s may be called at the service users request or if there is any alert from a Telecare sensor and you do not confirm all is well.
32. Do you have a family member/friend/neighbour who can act as a keyholder?*
  
  Yes
  
  No
33. 1. Please provide their:
  2. Name
  3. Your Address
    
    OSG Postcode Search (Custom drop-down list)
    
    Postcode
    
    Address
  4. Contact Telephone Number
34. Your application can not proceed at this stage without one keyholder, please telephone Home Safety Service to discuss this and seek further advice on 01506 284440 (option 1).

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Contact us about Technology today

Technology Enquiry

Are you applying for yourself or someone else?

Applicant Details

Address

Contact Details

GP Details

Reason For Enquiry

Keyholder Details