Package Offers

Package Offer Form

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

Name

DOB

Partners name living at same address

Address

Telephone

Mobile

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.

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