Test – Apply for Telecare Services

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    1st Applicant

    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 tel No (required)

    Mobile tel No

    Date of birth (required)

    What is your first language? (required)

    Religion

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

    Name of telephone service provider: e.g. BT

    What level of service is required (see below) (required)

    Contact OnlyMobile Response

    Contact Only: 24 hour Telephone support from our dedicated contact team.

    Mobile Response: Direct call-out support from our highly trained mobile wardens.

    Would you like information in large print or braille? (required)

    YesNo

    Are you or the second applicant in receipt of benefits? (required)

    YesNo

    If so, what benefits do you receive?

    1st Applicant - Medical Details

    Doctors name/Surgery (required)

    Address (required)

    Postcode (required)

    Telephone No

    OOH Tel No

    1st Applicant - Medical Conditions

    To help us provide a quality service, please provide details of any Medical Conditions so that we can make sure you receive the support you need.

    Cardio Vascular

    Heart ConditionAnginaCirculation problemsHigh blood pressureLow blood pressureStroke

    Medical Conditions

    CancerDiabetesEpilepsyBlood disordersArthritisOsteoporosis

    Respiritary

    AsthmaBreathing difficultiesBronchitisOxygen at home

    Sensory

    BlindPartially sightedProfoundly deafHearing aidMuteHard of hearingPoor concentrationLearning difficultiesMemory lossAnxietySpeech difficulties

    Cardio Vascular

    History of fallsPoor mobilityAids used

    Other please specify

    Please tell us about any prescriptions that you take, e.g. warfarin.

    Prescriptions

    Add 2nd Applicant (optional)

    Title

    MrMrsMsMissOther

    First Name (required)

    Last Name (required)

    Known as

    Date of birth (required)

    Relationship (required)

    Email address (required)

    Mobile tel No (required)

    Add 2nd Applicant Medical Details (if applicable)

    To help us provide a quality service, please provide details of any Medical Conditions so that we can make sure you receive the support you need.

    Doctors name/Surgery

    Address

    Postcode

    Telephone No

    OOH Tel No

    Add 2nd Applicant Medical Conditions (if applicable)

    Cardio Vascular

    Heart ConditionAnginaCirculation problemsHigh blood pressureLow blood pressureStroke

    Medical Conditions

    CancerDiabetesEpilepsyBlood disordersArthritisOsteoporosis

    Respiritary

    AsthmaBreathing difficultiesBronchitisOxygen at home

    Sensory

    BlindPartially sightedProfoundly deafHearing aidMuteHard of hearingPoor concentrationLearning difficultiesMemory lossAnxietySpeech difficulties

    Cardio Vascular

    History of fallsPoor mobilityAids used

    Other please specify

    Please tell us about any prescriptions that you take, e.g. warfarin.

    Prescriptions

    Visitor Details

    Please provide details of regular home visits or services received e.g. Nurse, Home care.

    Visitor type

    Tel No

    Name

    Next of Kin/Key Holder Details

    Please provide details of key holders and/or contacts who we can call on your behalf in the event of an emergency call.

    Title (required)

    MrMrsMsMissOther

    First name (required)

    Last name (required)

    Relationship (required)

    Date of Birth (required)

    Address line 1 (required)

    Address line 2 (required)

    Postcode (required)

    Home tel No

    Mobile tel No

    Work tel No

    Preferred/First language (required)

    Key holder ? (required)

    YesNo

    Add second Next of Kin/Key Holder details (optional)

    Please provide details of key holders and/or contacts who we can call on your behalf in the event of an emergency call.

    Title

    MrMrsMsMissOther

    First name

    Last name

    Relationship

    Date of Birth

    Address line 1

    Address line 2

    Postcode

    Home tel No

    Mobile tel No

    Work tel No

    Preferred/First language

    Key holder ?

    YesNo

    Add third Next of Kin/Key Holder details (optional)

    Please provide details of key holders and/or contacts who we can call on your behalf in the event of an emergency call.

    Title

    MrMrsMsMissOther

    First name

    Last name

    Relationship

    Date of Birth

    Address line 1

    Address line 2

    Postcode

    Home tel No

    Mobile tel No

    Work tel No

    Preferred/First language

    Key holder ?

    YesNo

    Property Information

    Do you have a Key Safe? (required)

    YesNo

    Type of Property ? (required)

    HouseBungalowFlat

    Property is (required)

    Owner OccupiedCouncil RentedPrivate RentedHousing RentedOther

    Do you have a pet living at the property? (required)

    YesNo

    If yes, please state

    Do you have a working telephone line? (required)

    YesNo

    Do you have a working electric plug socket close to your telephone line (within 1 metre)? (required)

    YesNo

    Further Information

    How did you hear about Telecare Cardiff? (required)

    Friend/NeighbourHospitalWebsiteGP SurgeryNewspaperOther

    If other, please specify

    Is there any additional information that you would like to tell us?

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