Intouch24 Online Application Form
Complete Part 1 and if applicable Part 2 and then send using the SEND button after completing the security information
The information will be checked at our offices and we will contact you by telephone to confirm details and make all arrangements. No payment is require when you send this application.

 

Intouch24 Application Part 1

Client's Name
Client's Address
Client's Home Telephone Number
Client's Mobile Telephone Number
Client's Email Address
Referral Code if applicable
Discount Code if applicable
Main Contact's Name if not Client
Main Contact's Telephone number if not Client
Equipment Delivery address if not Client's
Equipment Delivery telephone number if not Client's
Level of Service Require for 3 year commitments	Standard _____Enrolment & Equipment £199 Annual £365 Standard Plus__Enrolment & Equipment £224 Annual £365 Advanced_____Enrolment & Equipment £299 Annual £456 Advanced Plus_Enrolment & Equipment £324 Annual £456 Mobile________Enrolment & Equipment £39 Annual £199 None of these please calculate the pricing for me
Calculate the cost for other commitment periods for me	NO - I am using the 3 year period options aboveyes
Service level required for other commitment periods	Using Standard options above Standard Standard Plus Advanced Advanced Plus Mobile Other - please call me to discuss my requirements
Years commitment for us to calculate if applicable	Using Standard option above1245Other - we will call you to discuss
Is the Client taking medication	YesNo
Medical & Medication Details (write NONE if none)
Doctors Name
Doctors Address
Doctors Office Telephone number
Doctors Out of Hours telephone number
Name of Next of Kin
Address of Next of Kin
Next of Kin Home Telephone
Next of Kin Mobile Telephone number
Next of Kin email address
Name of person living with Client (write NONE if none)
Relationship of any person living with Client
Any details of Pets (name, type of animal)
Any other Client Details we should know
Keyholder 1 Name
Keyholder 1 Address
Keyholder 1 Home Telephone number
Keyholder 1 Mobile Telephone number
Keyholder 1 Email Address
Keyholder 2 Name
Keyholder 2 Address
Keyholder 2 Home Telephone number
Keyholder 2 Mobile Telephone number
Keyholder 2 Email Address
Keyholder 3 Name
Keyholder 3 Address
Keyholder 3 Home Telephone number
Keyholder 3 Mobile Telephone number
Keyholder 3 Email Address
Name of your home telephone provider	CYTAPrimtelBTTelefonicaFrance TelecommPTAnotherNone
Preferred Ambulance Service	State Ambulance ServicePrivate Ambulance Service
Name and Telephone number of Private Ambulance Service if applicable
Preferred Destination Hospital details
I agree to Intouch24 terms and conditions below	YES NO form generator
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The small print terms and conditions of our service agreement with you.

The British Care Trust

 

1. Will undertake to monitor your equipment 24 hours a day,365 days a year.

2. Will on receiving an information alarm for assistance, take immediate action to contact a Keyholder, a Doctor or the Emergency Services or others as most appropriate and as indicated on this Application Form or as modified and updated from time to time by you.

3. Will make arrangements for replacement equipment as soon as is practicable should that supplied malfunction.

4. Cannot accept responsibility for supporting equipment or services not supplied by or purchased from ourselves.

5. Will supply equipment and services to the quality and conditions of our suppliers; such as Chubb and Senior Link Eldercare.

6. Cannot be held responsible for failure of the service due to circumstances beyond our control, such as calls not received by the Response Centre due to problems with telephone lines, or delay failure by the Emergency Services to respond or adverse weather conditions.

7. Can not accept responsibility if delays occur in answering the User due to problems with the User’s telephone line being out of service, occupied by an answering machine or service, fax machine, internet connection or other telephony equipment (or from adverse weather conditions)

8. Reserves the right to (i) end the Service at the discretion of the Response Centre Manager, for example in cases of misuse or non-payment (although every possible assistance will be given if the User has financial problems) and (ii) review the price of the service fee and to notify the User or Users Representative of any change in the service fee charge.

 

You or your Representative agree to:

1. Pay The British Care Trust or its authorised Agent service fees and setup fees as advertised.

2. Ensure that the Keyholders listed have been contacted, are willing to participate, and have a key to the User’s home.

3. Inform The British Care Trust of any relevant changes to the User’s personal circumstances or to Keyholder details.

4. Inform The British Care Trust of periods when you are going to be away from home, eg on holiday or a stay in hospital or visting family etc.

5. Take reasonable care of The British Care Trust equipment and will be responsible for any breakage, loss or accidental damage.

6. Test the Equipment by activating an alarm at least once a month to ensure that it is working properly.

7. Take responsibility for covering The British Care Trust equipment under the your household insurance policy.

8. Give 28 days written notice of requirement to terminate the service.