Willow Court - Register your interest Completing this form To be able to process your request we need some information about the intended resident to enable us to carry out a suitability assessment. Please provide as much information as you can. Your contact details First name * Last name * Full address * Email Telephone Are you registering for yourself? * Yes No Date of birth * What's the name of your GP surgery? * GP surgery Address * Do you currently receive services from Adult Social Care? * Yes No Not sure Residents contact details First name * Last name * Address * Email address Date of birth * What's the name of your GP surgery? * GP surgery Address * Do you currently receive services from Adult Social Care? * Yes No Not sure About you Apartment type * One bedroom apartment Two bedroom apartment Either Do you currently have a care need * Yes No Current care need * Please provide us with information about your current level of care, this will enable us to monitor how effective our communications are in the community. Would you like arrange a viewing of the show home? * Yes No Nearest availability Please allow 3 working days from today. Today Clear A member of the team will get in touch with you shortly regarding your preferred date. Data protection and marketing I am happy to receive information from you * We would like to keep you informed about this scheme and other similar Extra Care options. We only collect limited information for this purpose. Please be advised that some of this data may be stored outside of the European Economic Area (EEA) (See Section 10 of the privacy notice). For more information please refer to our Data Protection page. For more information about how we collect, use and store your information please see our fair processing notice. Yes Where did you hear about Willow Court * Please tick all applicable options Advert in newspaper / magazine Attended an event Bus shelter poster Discovering Whittlesea / Discovering March magazine Facebook Family or friend Leaflet / brochure Other Pinterest Referral from GP, nurse or care worker Search engine (google etc) Signage Twitter Amplius website
