Confirmation

1
Cart Review
2
Checkout
3
Confirmation

Your payment has been successful, in order for your device to be programmed, tested and dispatched, we need you to complete the Emergency Contact Form:

Your device cannot be posted without this info:

1.

Person who placed the order (account holder)

First Name *

*We need this info to continue.

Last Name *

*We need this info to continue.

Phone Number *

*We need this info to continue.

Email Address*

*We need this info to continue.

2.

Alarm user details

User's First Name
User's Last Name
Gender
Date of birth
Address Line 1
Address Line 2 (Optional)
Town/City
Postcode
User’s email address
User's Mobile Telephone Number
3.

Alarm user's doctors details

Surgery or Doctor's Name
Surgery Address
Surgery Telephone Number
4.

Alarm user's medical history

Please provide further medical information
5.

Medication/medical items we need to be advised of

6.

Allergies to medicine

Others
7.

Blood thinners

Please state any other medical conditions or allergies not listed
NHS Number
Do you have a Key Safe?
If Yes, please provide the keysafe number and location
Home care provider
Number of visits per day
8.

Emergency contact 1 (First person you would like us to contact in an emergency)

First Name
Last Name
Relationship
Are they a key holder?
Can this emergency contact arrive at the property within 45 minutes in an emergency?
E-mail address
Mobile Telephone Number
Home Telephone Number
Address Line 1
Address Line 2 (Optional)
Town/City
Postcode
9.

Emergency contact 2 (Second person you would like us to contact in an emergency)

First Name
Last Name
Relationship
Are they a key holder?
Can this emergency contact arrive at the property within 45 minutes in an emergency?
E-mail address
Mobile Telephone Number
Home Telephone Number
Address Line 1
Address Line 2 (Optional)
Town/City
Postcode
10.

Emergency contact 3 (Third person you would like us to contact in an emergency)

First Name
Last Name
Relationship
Are they a key holder?
Can this emergency contact arrive at the property within 45 minutes in an emergency?
E-mail address
Mobile Telephone Number
Home Telephone Number
Address Line 1
Address Line 2 (Optional)
Town/City
Postcode
11.

Emergency contact 4 (Fourth person you would like us to contact in an emergency)

First Name
Last Name
Relationship
Are they a key holder?
Can this emergency contact arrive at the property within 45 minutes in an emergency?
E-mail address
Mobile Telephone Number
Home Telephone Number
Address Line 1
Address Line 2 (Optional)
Town/City
Postcode
12.

Emergency contact 5 (Fifth person you would like us to contact in an emergency)

First Name
Last Name
Relationship
Are they a key holder?
Can this emergency contact arrive at the property within 45 minutes in an emergency?
E-mail address
Mobile Telephone Number
Home Telephone Number
Address Line 1
Address Line 2 (Optional)
Town/City
Postcode
13.

Further information

Please use this section if there is anything further to add to the alarm user's account.

14.

VAT exemption declaration

PLEASE ONLY COMPLETE IF YOU ARE CLAIMING VAT EXEMPTION

  • Eligibility Criteria:

    Under UK law, you may be eligible for VAT relief if you have a physical or mental impairment that has a long-term and substantial adverse effect on your ability to carry out everyday activities, or if you have a chronic illness. VAT exemption also applies to products specifically designed for, or adapted for, use by disabled individuals. <a href="#">Learn more here</a>

  • Declaration:

    By completing this form, you are confirming that you qualify for VAT exemption under Group 12 of Schedule 8 of the Value Added Tax Act 1994. You agree that the equipment being purchased is for your personal use or the use of a person to whom you are legally responsible for.

  • Instructions:

    Please complete the fields below with your personal details and the nature of your disability or chronic illness. This information is required to verify eligibility for VAT relief.

First Name
Last Name
Address Line 1
Address Line 2 (Optional)
Town/City
County
Postcode
I declare that I have the following disability or chronic sickness
Date of declaration

Data protection & consent
By submitting this form, you confirm that the information provided is accurate to the best of your knowledge and that you are authorised to provide it. You explicitly consent to HelpAlert processing the health, medical and vulnerability information provided in this form, and sharing relevant information with our authorised 24-hour monitoring provider where necessary to provide the monitored alarm service and respond appropriately to an alarm or emergency.

Please see our Privacy Policy for more information about how we use and protect personal data.

When you submit this form, you will receive a confirmation email saying “Thank you - we’ve received your Emergency Contact Form.”

If you do not receive this email within a few minutes, please contact us on 01273 055049 or email careteam@helpalert24.co.uk so we can help straight away.