Priority Services Register

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This field is for validation purposes and should be left unchanged.

Name*

First name Last name

Customer Account Number*

Address*

Street Address Address Line 2 City Postcode Country

Telephone Number*

Email Address*

Date of Birth*

DD slash MM slash YYYY

Medically Dependant: Please tick the reason you would like to be added to the Priority Services Register:

Mental Health

Dementia

Dialysis

Chronic or Serious Illness

Temporary

Temporary life changes i.e. recent bereavement, seperation

Young adult house <18 (bill payer is under 18 years of age)

Pensionable age >65

Post hospital recovery i.e. restricted mobility for a period.

Families with young children (below 24 months). Please complete your youngest child's date of birth

DD slash MM slash YYYY

For post hospital recovery, please enter your expected recovery date:

DD slash MM slash YYYY

Communicaton

Language

Blind

Partially sighted

Developmental condition

Hearing impairment

Speech impairment

If visually impaired – Would you like to receive your bills in one of the following formats?

Braille

Large Print

Audio

Mobility

Physical impairment

Restricted hand movement

Unable to answer door

Would you like us to use a password when contacting you by telephone or visiting your home?*

Yes

If yes, please provide the password (between six (6) and ten (10) characters):*

In the event of a loss of supply are you, or someone within your property able to collect water if necessary?*

Yes

Does anyone have power of Attorney to deal with your finances? If yes please provide your attorney's name in the field below so that we can add them to your account:

Signature*

Customer Declaration*

I give consent for the personal data provided within this form to be used for the purpose of this application

I consent to the information I have provided on the form being used to add me to the Priority Services Register.

This means that Leaf Water may share my details in the event of a supply emergency with your trusted partners so that if I am in need, you can deliver bottled water.

I understand that Leaf Water may occasionally contact me by telephone, email, text or in person to make sure I am given the best support for my needs.

I understand that if my situation changes, I can tell Leaf Water and they will change my details or remove me.

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Date*

DD slash MM slash YYYY

CAPTCHA

Priority Services Register

My Account

Your Water

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