Is the referral for a Basic Alarm Package? Yes No The person must be capable of pressing a trigger/button to summon assistance in the event of an emergency. 1 Alarm Unit linked via the landline telephone to a 24 hour control centre 1 Pendant or 1 Falls Detector (the person will not require both) Up to 2 Linked Smoke Detectors Key Safe If you require other Telecare equipment detail your concerns and what outcomes you aim to achieve. Provide details of who to contact to arrange installation if not the customer COMMENTS Name Address Tel No Relationship IF ANY Who needs to respond to the person in the event of an emergency Yes No Does the person accept a responder may visits in the event of an emergency? List below the names of people who need to be contacted in the event of an emergency and what part they will take:- NOK Next of Kin – Emergency Contact Only EC – KH Is a Key Holder – RES Is a responder and able to go and check on the person in an emergency – N R Name & E K Title Address with Postcode Telephone Numbers O E Surname C H K S Home Mobile Work Home Mobile Work Comments Property Details
Is the referral for a Basic Alarm Package? Yes No The person must be capable of pressing a trigger/button to summon assistance in the event of an emergency. 1 Alarm Unit linked via the landline telephone to a 24 hour control centre 1 Pendant or 1 Falls Detector (the person will not require both) Up to 2 Linked Smoke Detectors Key Safe If you require other Telecare equipment detail your concerns and what outcomes you aim to achieve. Provide details of who to contact to arrange installation if not the customer Name Address Tel No Relationship COMMENTS IF ANY Who needs to respond to the person in the event of an emergency Does the person accept a responder may visits in the event of an emergency? Yes No List below the names of people who need to be contacted in the event of an emergency and what part they will take:- NOK – Next of Kin EC – Emergency Contact Only KH – Is a Key Holder RES – Is a responder and able to go and check on the person in an emergency Title Name & Surname Address with Postcode Telephone Numbers N O K E C K H R E S Home Mobile Work Home Mobile Work Comments Property Details
telecare_professional_referral_form_typing_handwriting_v_2_.docx