Use the form below to apply for a Careline product or service
You can also download a map of the areas we service.
In the form below, any field marked with * is mandatory
Are you contacting on behalf of somebody else? If yes please fill your details below. If no, please skip to the Client details section. *YesNo
Relation to client *N/AFamilyFriendGuardianCarerProfessional
First Name *
Date of Birth *
House Name/Number *
Address Line 2 *
Address Line 3
Address Line 4
Telephone (Daytime) *
E-mail Address *
Which Careline product would you like to apply for?
Careline Digital Sim Based Alarm
Careline Mobile Alarm
Careline Personal Alarm (Analogue)
Carbon Monoxide Alarm
Do you have an electrical socket near your main telephone point? *Not sureYesNo
Please use this box to tell us anything else regarding your application.
How did you hear about us? *BCKLWN WebsiteCareline Community Service websiteGoogle searchSocial mediaGP surgeryNewspaper advertisementWord of mouthFamily or friend
0 + 1 = ?Please prove that you are human by solving the equation *
Careline Community Service