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Please complete all fields marked *
About you
Title
First name help text
Last name
Please enter a postcode
Please enter a house name or number
Please enter an address line 1
Please enter an address line 2
Please enter a town
Please enter a county
Please enter a postcode
Home phone is required
Mobile phone
Text phone
Email
If you would like to nominate a person as your contact for priority services, please tick below.
Nominate contact
Nominate contact
Home security visit: if you would like us to use a password when we visit you, please enter it below (no more than 10 characters).
 If you would like us to use a password when we visit you, please enter it below (no more than 10 characters).
Registration reasons
Please let us know your reasons for registering ticking all below that are applicable to you or someone in your household:
Nebuliser or Apnoea Monitor
Heart / Lung Machine or Ventilator
Dialysis, feeding pump and automated medication
Stairlift, hoist or electric bed
Oxygen Use
Oxygen Concentrator
Careline or Telecare
Medically dependant showering/bathing
Other electrical equipment which you rely on for your health, please specify below
Medical Equipment type
Blind
Partially sighted
Hearing impairment (inc deaf)
Mental Health
Additional presence preferred
Restricted hand movement
Over 60
Physical impairment
Medicine Refrigeration
Dementia(s)/Cognitive impairment
Families with children under 5
Developmental Condition
Temporary - Young adult householder under 18
Chronic illness
Temporary - post hospital recovery
Temporary - life changes
Speech impairment
Water Dependant
Unable to answer door
Poor sense of smell/taste
Other information
English is not my first language
Please specify your first language if not english
Select the how did you hear about us choice
Other information for hear about us choice
What submitting this form means to you

Terms of registration

By submitting this form you are confirming that you understand we may need to pass details to a third party such as British Red Cross, Local Authority or Emergency Services, in order to provide you with priority services.

We will not use or pass your details to a third party for marketing purposes.

If you have a nominated contact, you are giving your explicit consent for us to talk to your nominated contact on your behalf when providing priority services. This may mean we will share information about you and your electricity supply with them

Terms of registration consent

Sharing your details

With your consent, we can pass your details onto your energy supplier who may also offer services you can benefit from; like a nominee scheme, accessible information and a password protection scheme.
Sharing your details consent