Client Information Request

If you would like a copy of our publications or brochures, please complete and submit this form.

All fields marked * are mandatory.

	What would you like information about? * Please tick as many boxes as necessary and at least one.	Live-in Nursing Live-in Care and/or Companionship Funding Options Handbook If you are unsure whether you need a Nurse or Care Assistant please tick this box. This link may help you.
	Important: If you tick only 'Funding Options Handbook' you will not receive details about our care services or fees.
	Title* (Mr., Miss, Sir)
	First Name
	Surname*
	Address 1*
	Address 2
	Address 3
	Town*
	County*
	Postcode
	Daytime tel.
	Mobile tel.
	Evening tel.
	Email address*	Mandatory only if you have asked for the Funding Options Handbook
	How did you first hear about Consultus? (Please be specific)
	I am applying on behalf of	myself a friend or relative my client
	If applying on behalf of someone else, in which town/city does the client live?
	When would it be convenient to contact you?
	How many people in the household require care?
	Regulations set by Government and others may limit which types of service we can offer you.
	Please help us provide you with the right information by telling us who would be responsible for settling our account:	Client/family/private solicitor etc Insurance/annuity company Directly by NHS or local authority Directly by charity/other public fund holder By private and/or public funds (as yet unknown)
		Tip: You would tick the first box if you receive a local authority direct payment or charitable contribution then send us a personal cheque.
	Some people need us to provide assistance urgently. Please help us to prioritise your request.
	Care/Nursing may be required:	Within 1 week Within 1 month At a later date (not urgent)
	Is there a spare bedroom on the premises?	yes no
	Briefly describe your needs or add any notes, queries or requests here:
	Please validate your request by entering the word from the image above...