Application Form

Thank you for choosing Telecare Cardiff

Please complete the following details as accurately as possible, if you need assistance, please ring 02920 537080 or email the team on telecare@cardiff.gov.uk

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:

Home tel No (required)
Mobile tel No

Date of birth

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)
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?
YesNo

Are you or the second applicant in receipt of benefits?
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




Title
MrMrsMsMissOther

First Name (required)
Last Name (required)

Known as

Date of birth (required)
Relationship (required)

Email address (required)
Mobile tel No (required)



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



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



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




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?
Friend/NeighbourHospitalWebsiteGP SurgeryNewspaperOther

If other, please specify

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


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