Referrals - Timesage

Timesage is an online platform so if you know the package you require and are confident in signing up yourself, all you need is an email address to get started. You may also use the email address of a trusted friend or relative as long as they are able to notify you of any actions required on your account.

This form can be used by health professionals and support workers to refer in to the service or customers who wish to discuss the packages available and require additional support to sign up.

Personal Details (of the lifeline customer)

Full name (required)

Date of birth (DD/MM/YYYY)

Address (required)

Postcode (required)

Contact telephone number (required)

Which lifeline service are you interested in? (required)

Who is your telephone provider?

Do you or a relative/friend have access to the internet?
YesNo

You will need to have or set up an email address

We will contact you discuss your options

Are you eligible for VAT relief?

You are eligible for VAT relief if you have a physical or mental impairment which has a long term effect upon your ability to carry out everyday activities? The VAT will be deducted at the checkout point once you input your reason for VAT relief.

YesNo

Have you completed this form on behalf of the person who requires the lifeline service?
YesNo

Your full name (required)

Organisation or relationship if family member (required)

Contact details (required)

Any other relevant information which may help us provide a better service,
e.g. stair lift, animals in the property, additional vulnerabilities etc.

Emergency Contacts or details of support worker

Contact 1 Name, Address and Telephone Numbers

Contact 2 Name, Address and Telephone Numbers

Contact 3 Name, Address and Telephone Numbers

Doctors Name

Lifeline Referrals

You are eligible for VAT relief if you have a physical or mental impairment which has a long term effect upon your ability to carry out everyday activities? The VAT will be deducted at the checkout point once you input your reason for VAT relief.

Support

Contact

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