This form has a maximum of 9 pages
Be Independent helps you live independently by bringing emergency care and specialist equipment to your home; our services can play a key role in supporting your better health and care, for you to maintain your own independence, in York.
In order to complete this form you may need to provide some or all of the following information:
- customer name, address and contact details
- details of anyone living with the customer, and of any pets
- details of the customer's doctor
- description of health condition(s) and any required solution
Please note: our system will 'time out' after 10 minutes. However, you will have 10 minutes to complete each page (not the overall form).
It is not possible to save partially completed forms, nor to retrieve information if the time out period is reached. For longer messages you may need to compose your feedback before starting this form. You can then 'paste' your text into this form once you're ready to send it.
Your privacy and security
Please do not use this form to send anything of a confidential nature, for example your credit card or bank details.
We do not rent, sell or trade your personal information; please see our privacy statement.