Careline AgreementYour Contact Details Are you contacting us for yourself, or on someone's behalf? If for yourself, please go straight to the Alarm User's Details section. If on someone's behalf, please complete this section. We will call you from 01553 616200 to discuss the alarm user's requirements.TitleFirst NameLast NameYour Phone No.Your emailRelationship to ClientAlarm User's DetailsTitleFirst NameLast NameDate of birthAddress Line 1Address Line 2TownCountyPostcodeHome PhoneLandline Provider (BT, etc)Is your property Privately owned Privately rented Housing Association / Council Mobile home or houseboatMobile NumberEmail AddressAlarm User's Doctor DetailsDoctor/SurgeryAddress Line 1Address Line 2Town/CityCountyPostcodePhone no.Alarm User's Medical InformationTick all that apply. Sight impaired Severely sight impaired Dementia Hard of Hearing Deaf Parkinson’s Disease Cancer High Blood Pressure Respiratory Problems** Epilepsy History of Heart Problems Wheelchair User Type 1 Diabetes Type 2 Diabetes Pacemaker Fitted Mental Health Issues** Please provide further details Please tick this box if the alarm user has no known medical conditionsMedication or items we need to be advised ofTick all that apply. Adrenaline pen / Epipen Insulin/Glucogel GTN spray Opiates*** Oxygen Nebulizer urinary catheter / colostomy / Ileostomy / stoma Inhalers Chemotherapy*** Please provide further detailsAllergies to medicationTick all that apply. Penicillin Aspirin Anti-inflammatories Morphine AnaestheticBlood thinnersTick any that are being taken. Aspirin Warfarin Anti-inflammatories Heparin Bisoprolol Clopidogrel Dabigatran Edoxaban Dipyridamole Dalteparin Rivaroxaban Fondaparinux TicopidineOther household residentsTell us about any other people in the same household.Resident 1 - First nameLast NameDate of birthRelationship to alarm userIs this person a next of kin? Yes NoMobile no.EmailMedical conditionsDoes this person require an additional pendant? Yes NoPendant typeTo add more residents please use the Additional Information section.Resident 2 - First nameLast nameDate of birthRelationship to alarm userIs this person a next of kin? Yes NoMobile no.EmailMedical conditionsDoes this person require an additional pendant? Yes NoPendant typeProfessional Carer DetailsTell us if a professional carer visits you.Care providerTelephone no.Carer visiting timesCarer visiting days Mon Tue Weds Thu Fri Sat SunKey safe detailsKeysafe locationKeysafe codeAlarm User's Emergency ContactsPlease list your responding emergency contacts here, including any that live with you. Your emergency contacts will be called in the order you list them here, until one answers and agrees a course of action to be taken. If you have more than 4 contacts, please list any additional in the Additional Information section.Contact 1 - First nameLast NameAddress Line 1Address Line 2TownCountyPostcodeLandline no.Work no.Mobile no.EmailRelationship to alarm userIs this contact: Next of kin? Keyholder? Power of Attorney?Contact 2 - First nameLast nameAddress Line 1Address Line 2TownCountyPostcodeLandline no.Work no.Mobile no.EmailRelationship to alarm userIs this contact: Next of kin? Keyholder? Power of Attorney?Contact 3 - First nameLast NameAddress Line 1Address Line 2TownCountyPostcodeLandline no.Work no.Mobile no.EmailRelationship to alarm userIs this contact: Next of kin? Keyholder? Power of Attorney?Contact 4 - First nameLast nameAddress Line 1Address Line 2TownCountyPostcodeLandline no.Work no.Mobile no.EmailRelationship to alarm userIs this contact: Next of kin? Keyholder? Power of Attorney?Additional informationPlease add any further additional information below.VAT reliefVAT relief eligibility You qualify for VAT relief if you have a disability or along-term illness (but please note the definition of thisbelow) and you are buying the product for your ownpersonal or domestic use. You don’t have to buy thegoods or services yourself. If your family member,carer or guardian buys the goods or services for you,and you qualify, then you won’t be charged VAT.For VAT purposes, you have a disability or long-termillness if you meet any of the following conditions:• You have a physical or mental impairment whichhas a long-term and substantial adverse effect uponyour ability to carry out everyday activities.• You have a condition that the medical professiontreats as a long-term illness, such as diabetes orheart disease.• You are terminally ill.Eligible conditions include: • Arthritis• Blindness• Cardiovascular Disease• Deafness• Diabetes• Epilepsy• Heart Disease• Hypertension• Kidney Disease• Motor Neurone Disease• Multiple Sclerosis• Parkinson’s Disease• Physically disabled•Terminally ill• OtherIf you are in any doubt as to whether you are eligible to receive our good or services without paying VAT, please consult HMRC.Name of alarm userPostcode of alarm userPlease select one of the following options: I declare that the alarm user qualifies for VAT relief, based on the information above I declare that the alarm user does not qualify for VAT reliefQualifying health condition(s)Terms & Conditions I confirm that I have read and understood the Terms & Conditions and accept the terms of service.First NameLast NameSubmit Form
