Section 1 - Details of person completing this form
Your relationship with the user of Easyphone-telicare service
Section 2 - Details of the user of the 24/7 Easyphone-Telecare service
Partners name living at same address
Name and contact number of residential key holder and access details
Car description and registration number
Your Easyphone mobile number can be supplied by Easyphone or the user can use their existing Sim.
Please enter the Mobile Number (Sim) used for the Easyphone Service
Section 3 - Details of the users existing medical conditions
Users existing medical conditions
Section 4 - Who we should contact in case of alarm.
Please list in order of priority
a) Name, mobile and other contact details
b) Name, mobile and other contact details
c) Name, mobile and other contact details
Section 5 - Details of your Doctor
d) Doctors Name
d) Surgery Name
d) Surgery Address
d) Carers Name and Contact Details
Section 6 - Payment Details
So we can offer a continued service after the 3 Months Free Trial please provide your preferred method of Payment for 24/7 Telecare Service charge at £15 per month, charged quarterly and can be cancelled at any time.
Start date: Month010203040506070809101112Year201620152014201320122011201020092008200720062005 Expiry date: Month010203040506070809101112Year201520162017201820192020202120222023202420252026
Name on card
Section 7 - Terms
Please confirm that you are happy to proceed so we can set-up the service for you. After the free trial we will automatically charge the credit card as detailed above at £15 a month and you can cancel at any time. Please note that Easyphone and its 24/7 Telecare Centre is not a healthcare provider and does not provide healthcare services. Our service is provided as back-up in case of emergency and the service can be affected by signal strength and call credits etc.
Check here if you accept these terms.