Llancarfan Coronavirus Response Please complete the questionnaire below to help link people together. Information will only be used for this purpose, and your contact details will be shared with those offering / requiring support.Name*Please enter your name First Last Address*Please enter your contact details House Name / Number Village ZIP / Postal Code Email LandlineMobileRegistering to*I am registering on here to...OFFER help and support if neededREQUEST help and support if availableOfferingI can offer help by... (Please select all that apply). Collecting medication/prescriptions Doing some shopping for those that need Delivering items to doorsteps Checking-in regularly with individuals on the phone Dog walkingNumber of OccupantsHow many people are there in the house?At risk?Are any individuals in the house classed as 'high risk' (pregnant, aged 70 or over, have a long-term condition or have a weakened immune system).Yes - there are 'high risk' individuals at the propertyNo - there are no 'high risk' individuals at the propertyHow can you be supported at this time?How can you be supported at this time? Please select all that apply. Having MEDICATION collected for you Deliveries of URGENT SUPPLIES Friendly PHONE CALLS Having the DOG WALKEDNext Medication CollectionWhen is your medication next due for collection? A member of the team will phone you a couple of days beforehand to check you still need it collected. PharmacyWhere does your medication need collected from? Please provide the full address of the Pharmacy if you are able.Contact*How can you be contacted? Please select all that apply. By landline phone By mobile phone By e-mail By postEmailThis field is for validation purposes and should be left unchanged.
