Section 1 - Details of person completing this form

    Your Name

    Your Address

    Your Email

    Your Telephone

    Your Mobile

    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.

    Card number

    Security code

    Start date: Expiry date:

    Name on card

    Cardholders address

    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.