Priority Services Register Form Please enable javascript to show this section. If you don't know how to do that please visit the following link: How to enable JavaScript in your web browser After javascript has been enabled in your browser you need to refresh this page to show this section properly and make this message disapear. H Thank you Modal title Please tell us your personal information filling the fields below * Title: Please select Mr Mrs Ms Miss Dr Other * First Name: * Last Name: Please tell us your contacts details filling the fields below Email: * Home Telephone: * Mobile Telephone: You must provide the Home Telephone Number or the Mobile Telephone Number If you would like us to hold contact details of someone who may contact us on your behalf, please provide their name and telephone number below. * Full Name: * Telephone Number: * Declaration: I confirm that the details I have given are true and correct. I give permission for you to store and use my personal details including sharing with other organisations* so that you or the other organisations* can provide me with the additional services. I understand that, by law, you are allowed to use my personal details in relation to additional services once I have given my permission. Please read our Privacy Notice to understand how we process your personal data. Please tell us your address filling the fields below Enter your postcode below and select address or type manually: Flat Number: You must provide the Building Name or the Building Number * Building Number: * Building Name: * Street Name: * Town/City: * Post Code: Please tell us about your needs below by ticking all the boxes that apply to you. You must tick at least one box. I have a nebuliser / apnoea monitor I rely on a heart / lung machine or ventilator I rely on dialysis, feeding pump or automated medication I have an oxygen concentrator I am blind I am partially sighted I have hearing difficulties I have a stair lift, bath hoist or electric bed I have speech difficulties I have a physical impairment I am of pensionable age I have a developmental condition I have difficulty communicating in English I have dementia / cognitive impairment I am unable to answer door I am medically dependent showering / bathing I have a chronic / serious illness I have medication that needs to be kept in the fridge I have a Careline / telecare system I have a poor sense of smell / taste I rely on oxygen use I have a family with children aged 5 or under I have restricted hand movement I require an additional presence I have mental health issues I require temporary assistance due to post-hospital recovery I require temporary assistance due to life changes I require temporary assistance as I am a young adult householder (<18) I am water dependent Please provide the month and the year of birth of your youngest child * Month: Please Select January February March April May June July August September October November December * Year: Please Select 2024 2023 2022 2021 2020 2019 You can set up a doorstep password which our staff will need to tell you before entering your home. If you would like to use this service, please enter your password below, using no more than 10 letters. Password Password Confirmation Please select the services you are interested in by ticking boxes below. * How did you hear about this service? Please select Word of mouth Awareness 1 leaflet Awareness 2 leaflet Awareness 3 leaflet Awareness 4 leaflet Awareness 5 leaflet Social Obligations leaflet Other Leaflet/correspondence Network Natter Events Partner - Carers Trust Partner – Maggie’s Partner - Alzheimer’s Partner - EPP Partner - HES Partner - British Red Cross Partner - Citrus Energy Partner - Citrus Energy Partner - Changeworks Partner - Alliance Scotland Partner - Other District Utility - WWU Utility - SGN Utility - Cadent Utility - Hafren Dyfrdwy Utility - Scottish Water Utility - Welsh Water Utility - Other Please refer to our Privacy Policy to understand how your data is treated once submitted via this form.