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
Please advise when you would like to start the service (required) What type of meal would you prefer ? (required) Main Meal (£5.09 each)Main Meal and Dessert (£5.88 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
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
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
Primary contact Full Name (required) Telephone number (required) Relationship (required) Keyholder? (required) YesNo Secondary contact Full Name Telephone number Relationship Keyholder? YesNo
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