Priority Services Register form page

Title

First name

Last name

Home Tel

Mobile Tel

Email

Address - first line

Address - second line

City

Postcode

Contact preferences Phone Email Post

Would you like for us to set up a password to enter your premises?
If yes, we will contact you through your details given to set up the password.

Password Yes No

Nominated Person Details

Is there anyone we can contact in case of a power cut that has the ability to aid you? If no, please skip

NP Title

NP First name

NP Last name

NP Home Tel

NP Mobile Tel

NP Email

Household needs

Please tell us about the needs of your household below by ticking all boxes that apply:

Medically Dependent Equipment Oxygen Use Medicine refrigeration Assisted electric showering Stair lift, hoist, electric bed Nebuliser and apnoea monitor Heart, lung & ventilator Dialysis, feeding pump/automated medication Oxygen concentrator Careline/Telecare system

Mobility impairment, disability or mental health condition Chronic/serious illness Restricted hand movement Physical impairment Developmental condition Dementia Poor sense of smell Mental health Unable to answer door/restricted movement

Are you of Pensionable Age Yes

Communication Impairment Hearing/speech difficulties (inc. Deaf) Blind Partially sighted

Do any of these fit your circumstances? Temporary life changes/other Post hospital recovery Young adult householder (<18) Family with young children, 5 or under

Other: Please tell us your concerns below

Declaration
By submitting this form, I am providing consent to Vattenfall Networks to process the information provided in accordance with our data protection policy. I also understand that my data can be shared to other companies for the purpose of providing this Priority Service Register. The information provided above is true to the best of my knowledge.

I agree Yes

Priority Services Register

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