Scottish Water Additional Support Register

1. Additional Support Register

Please complete to ensure Scottish Water has all your information to be included in our Additional Support Register.

Question Title

* 1. Are you already registered on the Additional Support Register?

Yes

Question Title

* 2. If YES, do you wish to remain on the register?

Yes

Question Title

* 3. Contact Details

Forename *

Surname *

Address 1: *

Address 2: *

City/Town: *

Region

Postcode *

Email Address:

Phone Number: *

Question Title

* 4. Need Category
Please tick the category below which best applies to your situation

Dialysis / Kidney Problems

Mental Health (Independant living within the community but with intermittent support)

Deaf / Hearing Impairment

Blind / Visual Impairment

Water for Medication

Low Immune System

Mobility Issues

Elderly or Infirm

Strict Hygiene practices (strict washing practices for chronic gastrointestinal illness/diarrhoea,colostomies,ileostomies,leaking fistulae & continence problems)

Care Support (Carers who have to be present at all times within the property, with the person they are caring for)

Non English Speaking

Any additional information:

Question Title

* 1. Are you already registered on the Additional Support Register?

Question Title

* 2. If YES, do you wish to remain on the register?

Question Title

* 3. Contact Details

Question Title

* 4. Need CategoryPlease tick the category below which best applies to your situation

* 4. Need Category
Please tick the category below which best applies to your situation