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Delivery Eligibility Form

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Delivery Eligibility Form

Please confirm that you are housebound and therefore eligible for our FREE Delivery due to one or more of the following: *

I am confined to my home due to a medical condition or disability.

I require assistance from another person or medical equipment (e.g., wheelchair, walker) to leave my home.

I have a chronic illness that makes leaving home a significant health risk.

I am under the care of a healthcare provider who has determined that travel outside the home is not feasible.

NHS Number

(you can find it on your repeat slip)

First Name *

Last Name *

Date of Birth *

Mobile Number *

(please enter a relative’s mobile number if you do not have one)

Email

Add another patient living at same address Remove

Address Line 1 *

Address Line 2

Town *

Postcode *

Signature

If you are human, leave this field blank.

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