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Social Care & Health
Adult Care
Telecare (MECS)
Telecare Application Form
Telecare Application Form
Please read the
Privacy Notice
before completing the form.
Telecare Application Form
Reason applying for the Telecare service
Why is a Telecare service required?
*
To assist a return home from hospital
Due to a fall within the last 12 months
To maintain independence
Carer Support
Who is completing this form?
*
I am applying for Telecare for myself
I am applying for Telecare for someone else
Applicants Details
Full Name
*
Address
*
Post Code
*
Mobile Contact Number
Landline Contact Number
Email
Optional
Gender
Optional
Male
Female
Perfer not to say
Date of Birth
*
Marital Status
Optional
Religion
Optional
Ethnicity
Optional
How would you like to be contacted?
Optional
Email
Phonecall
Text Message
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Last updated: Tuesday, January 26, 2021 2:56 PM