Personal Alarm and Telecare Referral Form

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Please be aware that this referral form is not meant to be used for emergency situations. If you or someone you know is in need of immediate assistance or is in a life-threatening situation, please call emergency services (999 from the UK). This referral form is specifically designed to initiate a request for telecare services only, and should not be used in emergency circumstances.

Referrer Information

Please provide accurate contact details for the person making the referral. This will allow us to reach out if needed and verify the legitimacy of the referral.

Patient/Client Information

Please provide the relevant information about the person who requires a personal alarm/telecare services. This information is important for us to ensure accurate communication and to better understand their needs.
Patient Address
Our commitment to safeguarding your privacy: When you submit the patient referral form, rest assured that the personal information is handled with the utmost care. The information provided in this referral form will be used solely for the purpose of facilitating the telecare services that are required. We do not share your personal information with any third parties without your consent, unless required by law. Our staff members who handle your data are bound by strict confidentiality agreements and adhere to strict privacy protocols. For detailed information on our commitment to safeguarding your personal data, we encourage you to review our Privacy Notice.
We would love to keep you informed about our products and services that are designed to connect and protect people. Please let us know if you would like to receive updates by checking the relevant boxes: (Optional)
You can update your contact preferences at any time by calling us on 028 2036 0280 or by sending us an email to We value your choices and want to ensure that you receive communications from us in the manner that suits you best.**
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