Name (required)

Address (required)

Post Code

Telephone Number

Date of Birth (required)

If you are completing this form on behalf of someone else, please let us know your

Full Name

Telephone Number

Position/relationship

I am applying for Salford Care on Call service because

Because of a serious health problem or medical position
Because of a disability
To feel more secure
Because I live alone

For another reason

Where did you first hear about the Salford Care on Call service?
Social worker Doctor/hospital nurse Housing office Relative or friend Advertisement Flyer Other (please state)

Other

We will use this information for the purposes of better understanding your needs and how we can improve our service. We may share this information with selected third parties.
Please tick this box if you do not want us to do this

You have the right to receive a copy of information held about you in our records for which we charge a small administration fee. You also have the right to correct any inaccuracies in the information.

I confirm that I have a telephone line and modern push-in telephone socket with an electrical socket located within 2 metres (approximately 6 feet) of the socket and I understand there is a weekly charge for this service.