Checking in-Checking in at Home

Who are we checking in on?

* Denotes a mandatory field

Their full name*

What should we call them on the telephone?* (eg 'Dot', 'Mr Smith')

What is their telephone number?*

The first line of their address

The second line of their address

Town

County

Post Code

Would you like to record personalised messages for the checking in service? (You can always change this later, using the instructions in the email we will send you). Yes

When should we check in on them?

Remember that you can check in on them once, twice, or three times a day. NB If you only want to check in on them once a day, leave the other two times blank.

The first call should be at:

The second call should be at:

The third call should be at:

If there is no answer, who do we call?

If there is no answer from the person you are checking in on, we will call the following people, in order, until someone answers. You can choose to list more than one number for yourself (or another person) in different slots (eg work, home, mobile). You do not have to give more than one number or contact if you don't want to - however, for the service to run as smoothly as possible we do encourage you to list three numbers, preferably those with access to your relative's house. Please also only list numbers that will be accessible during the call times listed above.

First contact name*

First contact telephone number*

Second contact name*

Second contact telephone number*

Third contact name

Third contact telephone number

About You

Please fill in the details of who is paying for the service

Your full name*

Your telephone number*

This email address will be used to send you a reminder of the details you have entered, plus information on what to do next.

Your email address*

The first line of your address

The second line of their address

Town

County

Post Code

What's your main reason for using this service:

How did you hear about Checking in at home:

May we keep you up to date with new products and services by email? Yes

Keep up to date with new products and services by phone? Yes

Keep up to date with new products and services by mail? Yes

Terms and payment

By checking this box, you confirm that you have read the terms and conditions of this service.* Review terms and conditions

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I agree to the terms and conditions

By checking this box, you confirm that you have the consent of the person you are checking in on to provide this service to them.* I have permission

Clicking on this button will take you to Paypal for payment processing. You will be making a payment to Brooks Healthcare (Telecare) Ltd who supply the Checking in at Home service. You will be returned to this website for further instructions once your payment has been processed.

Checking in at home 0844 822 0640

Who are we checking in on?

Guidance and examples