Lifeline application form – WordPress on Azure

Are you requesting a Lifeline for yourself or on behalf of someone else?(Required)

For myself

On behalf of someone else

Your details

Title

Please specify title

First name(Required)

Last name(Required)

Date of birth

Day

Month

Year

What is your relationship with them?(Required)

For example, son, daughter, care provider

Your contact details

Telephone number(Required)

Email(Required)

Details of the person who will require the Lifeline

Title

Please specify title

First name(Required)

Last name(Required)

Date of birth(Required)

Day

Month

Year

Contact details of the person who requires the Lifeline

Mobile number

Email(Required)

Do you live in Redbridge?(Required)

Yes

Does the person who requires the Lifeline live in Redbridge?(Required)

Yes

Please enter postcode and select address(Required)

Find addressSelected address

Address(Required)

Address Line 1 Address Line 2 City County Postcode

Home telephone details

Home telephone number(Required)

Who is the telephone provider?

Sky

Virgin

Talk Talk

Other

Please specify(Required)

Do you need a second pendant for another person?

Yes

Details of the other person second pendant is required for

First name

Last name

Mobile number

Date of birth

Day

Month

Year

Relationship to other person

GP and surgery details

Name of doctor(Required)

Is the GP in Redbridge?(Required)

Yes

Please enter postcode and select address(Required)

Find addressSelected address

Address of surgery or health centre(Required)

Address Line 1 Address Line 2 City County Postcode

GP telephone number

Please tell us about any medical conditions or allergies(Required)

Arthritis

COPD/Asthma

Hearing impairment

Osteoporosis

Diabetes

Heart condition

Alzheimer's

Dementia

Impaired sight

High/low blood pressure

Stroke

Other

Please specify here(Required)

Medical conditions or allergies of the person who requires the second pendant(Required)

Arthritis

COPD/Asthma

Hearing impairment

Osteoporosis

Diabetes

Heart condition

Alzheimer's

Dementia

Impaired sight

High/low blood pressure

Stroke

Other

Please specify(Required)

Home care details

Does the person requiring a lifeline receive home care?(Required)

Yes

Do you receive home care?(Required)

Yes

Home care company name(Required)

Home care company telephone number(Required)

Which days do they visit?(Required)

What are the timings?(Required)

Home care details for person requiring second pendant

Does the person requiring a second pendant receive home care?

Yes

Home care company name(Required)

Home care company telephone number(Required)

Which days do they visit?(Required)

What are the timings?(Required)

Why are you applying for a Lifeline?(Required)

Peace of mind

Independence

Health reasons

Safety and security

Reassurance

Other

Why does the person you are applying on behalf require a Lifeline?(Required)

Peace of mind

Independence

Health reasons

Safety and security

Reassurance

Other

Please specify(Required)

! Warning Two key holders are needed and they must live within 20 minutes driving radius of the client's address.

Can you provide two key holders?(Required)

Yes

Details of key holder 1

First name(Required)

Last name(Required)

Relationship to key holder(Required)

Is the key holder next of kin?(Required)

Yes

Contact details of key holder 1

Home telephone number(Required)

Work number

Mobile number

Does key holder 1 live in Redbridge?(Required)

Yes

Please enter postcode and select address(Required)

Find addressSelected address

Address(Required)

Address Line 1 Address Line 2 City County Postcode

Details of key holder 2

First name(Required)

Last name(Required)

Relationship to key holder(Required)

Is the key holder next of kin?(Required)

Yes

Contact details of key holder 2

Home telephone number(Required)

Work number

Mobile number

Does key holder 2 live in Redbridge?(Required)

Yes

Please enter postcode and select address(Required)

Find addressSelected address

Address(Required)

Address Line 1 Address Line 2 City County Postcode

! Warning A key safe will be needed at the property if you're unable to provide two key holders.

Is there a key safe already at the property?(Required)

Yes

Where did you find out abut the Lifeline service?(Required)

Social Worker or Occupational Therapist

Existing service user

Voluntary organisation

Doctor

Lifeline talk or demonstration

Other

Please specify(Required)

Privacy Statement

The information that you provide may be shared with the Ambulance Service, Police and Fire Brigade. This is to allow the best possible response if you are in need of medical, or other emergency assistance.

You should also be aware that any calls you make to the Lifeline Control Centre may be recorded for training and for delivering Lifeline Services. To find out more about our Privacy Notice, please visit our website page Privacy notices (opens in new window)

If you wish to access details of the data we hold for you, contact the Lifeline Control Centre on 020 8708 5897 or email lifeline@redbridge.gov.uk.

Consent(Required)

I give consent for my information to be shared with the Emergency Services as part of the privacy statement