Apply for Meals on Wheels

Please fill in the form below to check if you are eligible to receive our Meals on Wheels service

    Customer Details

    Title (required)

    MrMrsMsMissOther

    First Name (required)

    Last Name (required)

    Known as

    Address line 1 (required)

    Address line 2 (required)

    Postcode (required)

    Email Address (required)

    Home telephone number

    Mobile telephone number

    Date of birth (required)

    What is your first language? (required)

    Religion

    What language would you like to receive correspondence in? (required)

    Are you a Telecare customer (required)

    YesNo

    Section 2 - About you

    Please indicate why you need Meals on Wheels (Please tick all that apply) (required)

    Have difficulty preparing a meal safelyUnable to shop for foodLack nutritious mealsNeed support after discharge from hospital or illnessHave a mental or physical disability

    Please tick the box(es) below if there is anything that we may need to be aware of with the customer.

    Has poor mobilitySlow to answer doorGets confusedVisual impairmentHearing impairmentSpeech impairmentForm of dementiaRisk of falls

    Is there anything else we may need to know about the client?

    Will you need assistance with any of the following when the meal is delivered?

    Remove LidsPlate mealEncourage to eatGet cutleryHydration prompt

    Do you have a keysafe at the property? If yes, we will contact you for more information.

    YesNo

    Section 3 - Meal Preference

    Please advise when you would like to start the service (required)

    What type of meal would you prefer ? (required)

    Main Meal (£4.10 each)Main Meal and Dessert (£4.74 each)

    Please indicate what days you require the service (required)

    MondayTuesdayWednesdayThursdayFridaySaturdaySunday

    If we were to expand the service, would you consider any of the below? (Tick all that apply)

    Grocery PacksTea PacksFrozen Meals

    Section 4 - Health & Nutrition

    Please indicate any important likes and dislikes

    particular likes

    particular dislikes

    Please indicate any allergies below:

    CeleryGluten/cerealsSesame seedsEggsFishLupinPeanutsMolluscsMustardCrustaceansMilkNutsSoyaSulphites

    Please indicate any dietary preferences below:

    VegetarianVeganCarribbean/West IndianKosherAsian HalalMeals suitable for customers with diabetesGluten FreeMain meals that contain at least 400 calories and desserts that contain at least 300 calories

    Other allergy or dietary requirements

    Please tick the box if the client has any health conditions or concerns that may be relevant to the client’s nutritional requirements:

    DementiaPoor appetiteComplex dietLosing weight unintentionallyDysphagiaHeart conditionDiabetesAlcohol issuesUnderweightOverweightKidney diseaseSwallowing/Chewing issues

    Other health conditions or concerns

    Section 5 - Outcomes

    Please tick the outcomes you want to achieve as a result of having the service. (if applicable)

    Support Independent livingIncrease weightEat more of a balanced dietSafer living at homeFeel better nourishedDaily interactionLife is easier

    Sections 6 - Support Contacts

    Primary contact

    Full Name (required)

    Telephone number (required)

    Relationship (required)

    Keyholder? (required)

    YesNo

    Secondary contact

    Full Name

    Telephone number

    Relationship

    Keyholder?

    YesNo

    Section 7 - Payment and Authorisation

    We will send a bill at the end of the month for the meals received during that month. This can be paid by Direct Debit, credit or debit card over the telephone, cheque, or Postal Order. In some circumstances we can accept payment via an Allpay card or standing order. We never accept cash

    Preferred payment method (required)

    Direct DebitCredit or debit cardChequePostal OrderStanding order

    If someone other than the client is paying for the meal, please list their details below:

    Name

    Telephone

    Relationship to client

    Address

    Email

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