Priority Services Register sign up

Priority Services Register sign up
Your name*

TitleFirst NameSurname
Your address*

First line of address

Second line of address

CityState / Province

Post Code
Date of birth*

DayMonthYear
Email
example@example.com
Phone number
Alternative phone number
Preferred method of contact*

EmailPhone
Are you deaf or hard of hearing and use only text or another method to stay in touch?

YesNo
If you require a interpreter, please specify what language below:
Would you like to nominate another contact to act on your behalf in case of a power cut? This could be a close family member or friend.*

YesNo
Name

First NameLast Name
Address

First line of address

Second line of address

CityState / Province

Postal
Email
example@example.com
Phone Number
Do you or anyone in your household rely on electricity or water for home medical equipment?*

YesNo
Please tick all the reasons that are applicable to you or someone in your household:

Nebuliser or apnoea monitorMedicine refrigerationHeart or lung machine or ventilator dialysisDialysis, use of a feeding pump or automated medicationOxygen machineOxygen concentratorCareline or telecareStair lift, hoist or electric bedA medical condition which requires a constant water supplyOther
Please tick the box if you or someone in your household fits into any of the categories below:*

Blind or partially sighted.Over 60Restricted movement/unable to answer doorOf pensionable ageDementia(s) or cognitive impairmentWheelchair userA medical condition which requires a constant water supplyHearing (including deafness)Physical impairmentMental healthDevelopmental conditionChronic or serious illnessMedicine refrigerationNeed help reading the meterSpeech impairmentUnable to communicate in EnglishPoor sense of smell or tasteSpeech difficultiesOther
Temporary registration

Children under 5Post hospital recoveryYoung adult householdRecent change of circumstances
If you answered 'Recent change of circumstances' in the list above, please provide details below.
Would you benefit from your bill being in a different format?

In a language other than EnglishIn brailleIn large printRead to me over the phoneRead by text relayBy home visitOn a CD
Please provide us with any other relevant information:
If you would like your supplier to use a confidential password when they visit your home, please enter one here:
Data Protection

The information you supply on this form will be stored by the Centre for Sustainable Energy (CSE) and shared with one or more of the following: National Grid (NG), Scottish & Southern Electricity Networks (SSEN), your water utility, your energy provider. This will be done solely for the purpose of adding you to that utility provider's Priority Services Register (PSR).

Any of the organisations named above may in turn need to pass your details to a third party such as the British Red Cross, local authority or emergency services, in order to provide you with priority services.

CSE, SSEN, NG. your water utility or energy provider 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 NG, SSEN, your water utility or energy provider to talk to your nominated contact on your behalf when providing priority services. This may mean NG, SSEN, your water utility or energy provider will share information about you and your electricity or water supply with them.

If you are a NG customer in South Wales or the Midlands we will need to pass your details on to our partners at the Energy Saving Trust (Wales) or Citizens Advice (Midlands) for the purposes of signing you up to the PSR and providing additional advice if you have requested it.
I understand*

Please tick the box to confirm your understanding and agreement with the above statements
Do you struggle with bills or staying warm at home? Please let us know if you would like a member of the Home Energy Team to contact you to provide additional advice and support*

YesNo
Where did you hear about us?

Blue Badge applicationBus pass renewal applicationCouncil Tax Reduction letterMedequip (medical equipment installer)Medvivo Careline (health and care services)Great Western Hospital - SwindonSalisbury District HospitalPharmacyOther
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