Become A Member

Your Well-being Check

How often would you like us to keep in touch with you? *

Weekly

Fortnightly

Monthly

What time of the day? *

AM

PM

Do you live on your own? *

Yes

No

If No, who lives with you please *

E.g. Son, Daughter, Partner, Lodger etc

About You

Title *

First Name *

Middle Name

Surname *

Preferred Name *

Date of Birth *

Address First Line *

Apt, suite, etc.

Country

City

State

Zip code

Home Phone Number *

Mobile Phone Number *

Work Phone Number

Email

Gender *

Marital Status *

Single, Married, Cohabiting, Divorced, Widowed

Ethnicity *

Religion *

Sexuality *

E.g. Straight/Heterosexual, Bisexual, Lesbian, Gay

More About You

The questions in this section may seem intrusive, and this we know. The whole point of these questions is for us to know enough about you, especially in a case of an emergency.

Knowing this information could help us to support you better and adequately, if we ever find that we are seriously worried about your well-being, which also include your whereabouts.

Please note that if we have to contact the NHS in an emergency, we will ONLY disclose the information we know are needed, if asked. We have the right under the law to protect all the information you disclose to us, and we must also abide diligently by this under the law

Do you own any pet? *

Yes

No

If yes, what pet/s do you have? *

Do you use key safe? *

Yes

No

Do you usually require help to attend to your personal care? *

Yes

No

Are there any health issues you would like us to know about? *

Yes

No

If Yes, what are the health conditions please *

Would you class yourself as being disabled in any way? *

Yes

No

If yes, please state what your disability is *

Please tell us something about you *

E.g. Hobbies, likes, dislikes etc.

Other Support We May Be Able To Offer

Would you like us to give moral support if you are ever admitted into the hospital? *

Yes

No

Disclaimer about Moral Support *

Yes

No

By moral support, we mean to be a friend. We will not support you in decision making, we will not make any medical decision on your behalf, we will not support you to administer any treatment. It is purely to have someone by your side. A shoulder to cry on. Do you understand this

Your Other Interests *

About Your Next of Kin

Do you have a Next Of Kin? *

Yes

No

Is your Next of Kin in *

the UK

Abroad

Relationship To Next of Kin *

Next of Kin - Title *

Next of Kin - First Name *

Next of Kin - Surname *

Next of Kin - Email *

Next of Kin - Contact Phone Number *

Phone number of Next of Kin Abroad *

Address *

Apt, suite, etc.

Country

City

State

Zip code

Address of Next of Kin Abroad *

Apt, suite, etc.

Country

City

State

Zip code

Can we contact your next of kin in a case of an emergency? *

Yes

No

About your other Significant Person

Is there any other significant person in your life that you would like us to know about? *

Yes

No

Is your other Significant person in *

the UK

Abroad

Title *

First Name *

Surname *

Contact Phone Number *

Phone number of other Significant Abroad *

Address of Other Significant Person *

Apt, suite, etc.

Country

City

State

Zip code

Address of Other Significant Abroad *

Apt, suite, etc.

Country

City

State

Zip code

What's your relationship to your other significant person *

Can we contact this significant person in a case of an emergency? *

Yes

No

Next Page *

Anything Else

Is there anything you would like us to know about you? *

Yes

No

Other information you would like us to know about *

Do you have any burning question/s? *

Yes

No

Burning Questions

I am Unique! *

reCAPTCHA is required.