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.

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?

Nebuliser and apnoea monitor Heart, lung and ventilator Dialysis, feeding pump and automated medication Oxygen concentrator Other None

If you answered Other to the above, please specify

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

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

How long would 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? If 'yes' please enter their name and number below

Yes No

Nominated contact name

Nominated contact number

Would you like us to share your information?

Yes No