Carelink Application | FCC

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Carelink Application

1Your Details 2Enquiry Details

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Your Details

Forename

Surname

Phone Number

Email Address

Address

Recently Used Address

Address

If you are using a screen reader, do not fill in this field If you are using a screen reader, do not fill in this field

Enquiry Details

Date of birth

Landline number

Mobile number

Tenancy

Council Tenant Private Tenant Homeowner

Your Doctor

Name of Doctor

Surgery Address

Phone number of Doctor

Please list any medical conditions or disabilities

Contacts/Keyholders

Please list up to 3 contacts or keyholders in the event of an emergency. Responders must be within a 30 minute drive from the service user.

This information will be shared with the emergency services and Flintshire County Council Community Services Directorate and Delta Wellbeing monitoring Centre when required.

Keyholder 1

Relationship of Keyholder 1

Name of Keyholder 1

Address of Keyholder 1

Phone number of Keyholder 1

Mobile number of Keyholder 1

Keyholder 2

Relationship of Keyholder 2

Name of Keyholder 2

Address of Keyholder 2

Phone number of Keyholder 2

Mobile number of Keyholder 2

Keyholder 3

Relationship of Keyholder 3

Name of Keyholder 3

Address of Keyholder 3

Phone number of Keyholder 3

Mobile number of Keyholder 3

Is Carelink Required for Hospital Discharge?

Yes No

Please indicate earliest discharge date

Please allow 21 working days for installation

Keysafe Information

Keysafe code

Keysafe Position

Application Information

Name of person completing this application

Relationship to applicant

All responders are aware their details have been provided

Yes No

The applicant is aware of the information provided and has given consent for their details to be submitted

Yes No

Additional Information

I have read the privacy notice and agree to continue

.

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Privacy Policy

Privacy Policy

Flintshire County Council will process your personal information for the purpose of fulfilling our contract with you, to manage your application and continued provision for a Care-Link Alarm System. The sensitive personal information that you provide, will be used to enable relevant health and social care support to you within your home.

Your personal information will be passed to our data processor (Llesiant Delta Wellbeing, Unit 2 Dafen Industrial Estate, Heol Aur Dafen, Llanelli, South Wales SA14 8QN) who will provide the call monitoring service on our behalf.

Your personal information may be shared with the NHS, Police, or relevant third parties, if this is necessary as part of your contract to provide relevant support, or in an emergency.

Flintshire County Council will not share your information to any other parties or use it for any other purpose.

Your information will be retained for a period of 12 months following the termination/cessation of the service.

For more information on how Flintshire County Council processes information, please see:

English - http://www.flintshire.gov.uk/en/Resident/Contact-Us/Privacy-Notice.aspx Welsh - http://www.siryfflint.gov.uk/cy/Resident/Contact-Us/Privacy-Notice.aspx