Priority Services Details Update

These forms are only picked up during office hours. If you need to report, or request information about a power cut please click here.

There were errors on the form. Please correct them before you continue.

Title

First Name

Surname

Address

Postcode

Would you like to be removed from the Priority Service Register?

Yes No

Tel No

Mobile

Do you or anyone in your household rely on electricity for home medical equipment?

Sleep apnoea/nebuliser monitor Dialysis, feeding pump or automated medication Oxygen concentrator Heart/lung machine or ventilator Refrigerated medicine Medically dependent showering/bathing Stair lift/hoist or electric bed None

Do you have a stair lift, hoist or electric bed?

Yes No

Please tick the box if you or someone in your household fits into any of the categories below

If you answered 'Unable to communicate in English' above, please specify your first language here

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If you answered Temporary registration above, please tell us your reasons for needing to be registered temporarily here

Temporary impairment hospital recovery Temporary impairment young adult householder (<18)

How long would you like to be temporarily registered?

12 months 6 months Other

If you answered Other above, please specify how long

Please provide us with any other important information that you would like to tell us below

Would you like to add a nominated contact to act on your behalf?

Yes No

Nominated contact name

Nominated contact number

Important Information – please read. We may share your details with local responding agencies, trusted charities such as the British Red Cross. Your data will never be used for marketing purposes. In some cases we can share your information with your energy/utility (including water) suppliers, networks and meter operators so they can register you for their priority services. {{vm.getError('psrConsentId.priority-services')}}

Would you like us to share your information?*

Yes No

By ticking this box you are agreeing to our terms of use and PSR privacy policy. {{vm.getError('generalConsentId.general-priority-services')}}

Thank you

Thank you for updating your details.

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Priority Services Details Update

Thank you

Contact us

0800 6783 105

0800 096 3080