Apply for Telecare Service

By completing this form I agree that I am happy for Cyngor Gwynedd to share the contents of the form with the Galw Gofal monitoring centre (which is part of Conwy County Borough Council). I also agree that I understand and accept that there is a £5.55 weekly fee for the telecare service I am requesting.

Ar you filling out this form on behalf of another person? *

Contact details

First names *

Surname *

Address *

Instructions on how to get to the house if it is difficult to locate, and any health and safety considerations e.g pets

Date of birth *

Sex *

Phone number *

Second phone number

Email address

Preferred language *

Information about the home

Do you live on your own? *

Type of accommodation *

Tenure *

Does the accommodation have a broadband package or wi-fi? *

Does the property have a key safe? *

Further information about you

Do you live with any physical or mental health conditions? *

Note the main risks in the home and the reason for you application for the telecare package

Have you fallen in your home during the last sixth months *

Family doctors name *

Family doctor address *

Do you receive home care? *

Responders in an emergency

Please note the details of people we should contact in an emergency. If possible, note the details of 3 different responders. They should live fairly local to you and are ready to respond in an emergency e.g family members, friends, neighbours etc.

Responder in an emergency 1

Full name *

Relation *

Address *

Phone number *

Information about your next of kin

This person will be the second point of contact if we are not able to contact you.

Next of kin - name *

Next of kin - relation *

Next of kin - contact number *

I agree to the terms and conditions of the service *

I understand that there is a weekly fee for this Service *