ExtraCare registration form

First name: *

Surname: *

House/Flat name/Number: *

Road/Street name: *

Town:

City:

County:

Postcode: *

Email:

UU customer account number (you can find this from your water bill): *

Telephone Number (including STD code):

Mobile Number:

To ensure that we register you for the correct services, please tick the box that best describe your circumstances: * Blind Partially sighted Deaf Hard of hearing Disabled or limited mobility Learning difficulties Haemo dialysis at home

Do you have a serious medical illness?: Yes No

Could you please tell us about your illness or if there is anything else we should know?

Would you like us to send your bill in Braille?: Yes No

Would you like us to send you a large print bill?: Yes No

Would you like us to phone you with details of your bill before we send it to you?: Yes No

Would you like a friend or relative to receive your bill? (Please make sure you check with them before you give their details to us): * Yes No

If yes, then please fill in their name and address here:

First name: *

Surname: *

House/Flat name/Number: *

Road/Street name: *

Town:

City:

County:

Postcode: *

UU customer account number (you can find this from your water bill): *

Telephone Number (including STD code):

Mobile Number:

Email:

We have a password scheme to help protect you from bogus callers. Please let us know the password you would like us to use by entering it in the box below: