www.ukpowernetworks.co.uk
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2606:2800:233:1cb7:261b:1f9c:2074:3c
Public Scan
Submitted URL: https://www.ukpowernetworks.co.uk/sdc-psr-form
Effective URL: https://www.ukpowernetworks.co.uk/psr-form?utm_source=SDC&utm_medium=digital&utm_campaign=SDC-addition
Submission: On July 17 via manual from GB — Scanned from GB
Effective URL: https://www.ukpowernetworks.co.uk/psr-form?utm_source=SDC&utm_medium=digital&utm_campaign=SDC-addition
Submission: On July 17 via manual from GB — Scanned from GB
Form analysis 1 forms found in the DOM
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<form action="#" aria-describedby="error-3024290a-b305-4bd1-b072-03276cf5c103" class="DynamicForms_wrapper__gYSvo" id="3024290a-b305-4bd1-b072-03276cf5c103">
<div class="FormPage_formPage__klmHw">
<div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<div class="FormField_richText__Sl4AI">
<div class="RichText_richText__8j3h3" data-text-size="text-body-2">
<p>The Priority Services Register is free to join. It helps us to look after customers who have specific communication, access or safety needs. If you live in London, the South East or the East of England, we can offer extra support
when you need it, for example if you experience a power cut. To be added to our Priority Services Register, please complete our short form below.</p>
<p>If you would like to receive a copy of our Priority Services Register application form in large font, in EasyRead, or in Braille, please call <a href="tel:08001699970">0800 169 9970</a> or email us at
<a href="mailto:psr@ukpowernetworks.co.uk">psr@ukpowernetworks.co.uk</a> and we’ll be happy to arrange this for you. You can also download our EasyRead form and language forms from our
<a rel="noopener" href="https://www.ukpowernetworks.co.uk/power-cut/priority-services/resources-and-downloads" target="_blank">Priority Services resources and downloads web page</a>.</p>
<p>For more information on how we will treat your personal data, please read our <a rel="noopener" href="https://www.ukpowernetworks.co.uk/privacy-policy" target="_blank">Privacy Policy</a> and our
<a rel="noopener" href="https://www.ukpowernetworks.co.uk/power-cut/priority-services/psr-promise-and-keeping-your-data-safe" target="_blank">Priority Services Promise</a>.</p>
</div>
</div>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<div class="FormField_richText__Sl4AI">
<div class="RichText_richText__8j3h3" data-text-size="text-body-2">
<p><strong>Mandatory questions</strong></p>
<p>Questions which have a star (*) after them are mandatory fields. You will not be able to complete the form without answering these.</p>
</div>
</div>
</div>
</div>
</section>
</div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<h3 class="FormFieldset_formFieldTitle__SVUvX" role="group">Address</h3>
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<div class="PostCodeSearch_postCodeSearch___npR4 undefined"><label class="Label_label__dVF3q undefined" for="address">Address<span class="Label_asterisk__b2jlp"> *</span></label>
<div class="AddressLookUp_addressSearchBar__TCGhb"><input class="AddressLookUp_addressSearchBarInput__WzD3G" aria-controls="postcode-search_open" aria-expanded="false" placeholder="Search by postcode" aria-owns="postcode-search_open"
aria-label="postcode search" spellcheck="false" autocomplete="off" autocorrect="off" role="combobox" type="text" aria-describedby="error-address" id="address"><button class="button AddressLookUp_lensButton__AAYWg"
data-appearance="NewPrimaryButton" data-color="light" aria-label="Search" type="button"><span class="AddressLookUp_lensButtonText__4fDDh">Search</span><svg viewBox="0 0 16 16" class="Icon_icon__29ZJ9" aria-hidden="true"
focusable="false" fill="none" name="icon_search">
<title></title>
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</path>
<path d="M9.47339 9.47339L13.0001 13" stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
</svg></button></div>
</div>
</div>
</div>
</section>
</div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<h3 class="FormFieldset_formFieldTitle__SVUvX" role="group">Who should we contact about the property during a power cut?</h3>
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="primaryTitle">Title<span class="Label_asterisk__b2jlp"> *</span></label><input
aria-describedby="error-primaryTitle" class="Input_textInput__7uTHu" data-error="false" type="text" name="primaryTitle" id="primaryTitle" autocomplete="primary-title" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="primaryFirstName">First name<span class="Label_asterisk__b2jlp">
*</span></label><input aria-describedby="error-primaryFirstName" class="Input_textInput__7uTHu" data-error="false" type="text" name="primaryFirstName" id="primaryFirstName" autocomplete="primary-first-name" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="primaryLastName">Last name<span class="Label_asterisk__b2jlp">
*</span></label><input aria-describedby="error-primaryLastName" class="Input_textInput__7uTHu" data-error="false" type="text" name="primaryLastName" id="primaryLastName" autocomplete="primary-last-name" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="primaryTelephoneNumber">Preferred contact number<span
class="Label_asterisk__b2jlp"> *</span></label><input aria-describedby="error-primaryTelephoneNumber" class="Input_textInput__7uTHu" data-error="false" type="text" name="primaryTelephoneNumber" id="primaryTelephoneNumber"
autocomplete="primary-telephone-number" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="primaryMobileNumber">Alternative contact number</label><input
aria-describedby="error-primaryMobileNumber" class="Input_textInput__7uTHu" data-error="false" type="text" name="primaryMobileNumber" id="primaryMobileNumber" autocomplete="primary-mobile-number" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="emailAddress">Email address</label><input
aria-describedby="error-emailAddress" class="Input_textInput__7uTHu" data-error="false" type="text" name="emailAddress" id="emailAddress" autocomplete="email-address" value=""></div>
</div>
</section>
</div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<h3 class="FormFieldset_formFieldTitle__SVUvX" role="group">Is there anyone else you would like us to contact during a power cut?</h3>
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="alternativeTitle">Title</label><input
aria-describedby="error-alternativeTitle" class="Input_textInput__7uTHu" data-error="false" type="text" name="alternativeTitle" id="alternativeTitle" autocomplete="alternative-title" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="alternativeFirstName">First name</label><input
aria-describedby="error-alternativeFirstName" class="Input_textInput__7uTHu" data-error="false" type="text" name="alternativeFirstName" id="alternativeFirstName" autocomplete="alternative-first-name" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="alternativeLastName">Last name</label><input
aria-describedby="error-alternativeLastName" class="Input_textInput__7uTHu" data-error="false" type="text" name="alternativeLastName" id="alternativeLastName" autocomplete="alternative-last-name" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="alternativeTelephoneNumber">Preferred contact number</label><input
aria-describedby="error-alternativeTelephoneNumber" class="Input_textInput__7uTHu" data-error="false" type="text" name="alternativeTelephoneNumber" id="alternativeTelephoneNumber" autocomplete="alternative-telephone-number" value="">
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="alternativeMobileNumber">Alternative contact number</label><input
aria-describedby="error-alternativeMobileNumber" class="Input_textInput__7uTHu" data-error="false" type="text" name="alternativeMobileNumber" id="alternativeMobileNumber" autocomplete="alternative-mobile-number" value=""></div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="alternativeEmailAddress">Email address</label><input
aria-describedby="error-alternativeEmailAddress" class="Input_textInput__7uTHu" data-error="false" type="text" name="alternativeEmailAddress" id="alternativeEmailAddress" autocomplete="alternative-email-address" value=""></div>
</div>
</section>
</div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<h3 class="FormFieldset_formFieldTitle__SVUvX" role="group">Please let us know your reason for registering by selecting any of the options applicable to you or anyone else living in the property*</h3>
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Rely on medical equipment that needs electricity and/or water</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Nebuliser and apnoea monitor"
aria-checked="false" role="checkbox" tabindex="0" value="Nebuliser and apnoea monitor">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Nebuliser and apnoea monitor" class="Checkbox_text__1TGA3">Nebuliser and apnoea monitor</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Heart, lung and ventilator" aria-checked="false"
role="checkbox" tabindex="0" value="Heart, lung and ventilator">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Heart, lung and ventilator" class="Checkbox_text__1TGA3">Heart, lung and ventilator</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Dialysis, feeding pump and automated medication"
aria-checked="false" role="checkbox" tabindex="0" value="Dialysis, feeding pump and automated medication">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Dialysis, feeding pump and automated medication" class="Checkbox_text__1TGA3">Dialysis, feeding pump and automated medication</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Oxygen concentrator" aria-checked="false"
role="checkbox" tabindex="0" value="Oxygen concentrator">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Oxygen concentrator" class="Checkbox_text__1TGA3">Oxygen concentrator</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Medically dependent showering/bathing"
aria-checked="false" role="checkbox" tabindex="0" value="Medically dependent showering/bathing">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Medically dependent showering/bathing" class="Checkbox_text__1TGA3">Medically dependent showering/bathing</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Careline/telecare system" aria-checked="false"
role="checkbox" tabindex="0" value="Careline/telecare system">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Careline/telecare system" class="Checkbox_text__1TGA3">Careline/telecare system</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Medicines requiring refrigeration"
aria-checked="false" role="checkbox" tabindex="0" value="Medicines requiring refrigeration">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Medicines requiring refrigeration" class="Checkbox_text__1TGA3">Medicines requiring refrigeration</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Stair lift, hoist and electric bed"
aria-checked="false" role="checkbox" tabindex="0" value="Stair lift, hoist and electric bed">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Stair lift, hoist and electric bed" class="Checkbox_text__1TGA3">Stair lift, hoist and electric bed</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-relyOnMedicalEquipment" type="checkbox" name="relyOnMedicalEquipment" id="relyOnMedicalEquipment-Water dependent" aria-checked="false"
role="checkbox" tabindex="0" value="Water dependent">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="relyOnMedicalEquipment-Water dependent" class="Checkbox_text__1TGA3">Water dependent</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Would you like to have an additional, independent person present if our staff need to visit your property?</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-wouldYouLikeToHaveAnAdditionalIndependentPersonPresentIfOurStaffNeedToVisitYourProperty" type="checkbox"
name="wouldYouLikeToHaveAnAdditionalIndependentPersonPresentIfOurStaffNeedToVisitYourProperty" id="wouldYouLikeToHaveAnAdditionalIndependentPersonPresentIfOurStaffNeedToVisitYourProperty-Additional presence preferred"
aria-checked="false" role="checkbox" tabindex="0" value="Additional presence preferred">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="wouldYouLikeToHaveAnAdditionalIndependentPersonPresentIfOurStaffNeedToVisitYourProperty-Additional presence preferred" class="Checkbox_text__1TGA3">Additional presence preferred</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Chronic/serious illness</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-chronicSeriousIllness" type="checkbox" name="chronicSeriousIllness" id="chronicSeriousIllness-Yes" aria-checked="false" role="checkbox"
tabindex="0" value="Yes">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="chronicSeriousIllness-Yes" class="Checkbox_text__1TGA3">Yes</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Safety</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-safety" type="checkbox" name="safety" id="safety-Oxygen Use" aria-checked="false" role="checkbox" tabindex="0" value="Oxygen Use">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="safety-Oxygen Use" class="Checkbox_text__1TGA3">Oxygen Use</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-safety" type="checkbox" name="safety" id="safety-Poor sense of smell/taste" aria-checked="false" role="checkbox" tabindex="0"
value="Poor sense of smell/taste">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="safety-Poor sense of smell/taste" class="Checkbox_text__1TGA3">Poor sense of smell/taste</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Poor mobility</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-poorMobility" type="checkbox" name="poorMobility" id="poorMobility-Physical impairment" aria-checked="false" role="checkbox" tabindex="0"
value="Physical impairment">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="poorMobility-Physical impairment" class="Checkbox_text__1TGA3">Physical impairment</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-poorMobility" type="checkbox" name="poorMobility" id="poorMobility-Unable to answer door" aria-checked="false" role="checkbox" tabindex="0"
value="Unable to answer door">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="poorMobility-Unable to answer door" class="Checkbox_text__1TGA3">Unable to answer door</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-poorMobility" type="checkbox" name="poorMobility" id="poorMobility-Restricted hand movement" aria-checked="false" role="checkbox" tabindex="0"
value="Restricted hand movement">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="poorMobility-Restricted hand movement" class="Checkbox_text__1TGA3">Restricted hand movement</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Communication needs</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-communicationNeeds" type="checkbox" name="communicationNeeds" id="communicationNeeds-Blind" aria-checked="false" role="checkbox" tabindex="0"
value="Blind">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="communicationNeeds-Blind" class="Checkbox_text__1TGA3">Blind</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-communicationNeeds" type="checkbox" name="communicationNeeds" id="communicationNeeds-Partially sighted" aria-checked="false" role="checkbox"
tabindex="0" value="Partially sighted">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="communicationNeeds-Partially sighted" class="Checkbox_text__1TGA3">Partially sighted</label></span>
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</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-communicationNeeds" type="checkbox" name="communicationNeeds" id="communicationNeeds-Hearing impairment (including Deaf)" aria-checked="false"
role="checkbox" tabindex="0" value="Hearing impairment (including Deaf)">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="communicationNeeds-Hearing impairment (including Deaf)" class="Checkbox_text__1TGA3">Hearing impairment (including Deaf)</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-communicationNeeds" type="checkbox" name="communicationNeeds" id="communicationNeeds-Speech impairment" aria-checked="false" role="checkbox"
tabindex="0" value="Speech impairment">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="communicationNeeds-Speech impairment" class="Checkbox_text__1TGA3">Speech impairment</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-communicationNeeds" type="checkbox" name="communicationNeeds" id="communicationNeeds-Unable to communicate in English" aria-checked="false"
role="checkbox" tabindex="0" value="Unable to communicate in English">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="communicationNeeds-Unable to communicate in English" class="Checkbox_text__1TGA3">Unable to communicate in English</label></span>
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</div>
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</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Other health conditions</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-otherHealthConditions" type="checkbox" name="otherHealthConditions" id="otherHealthConditions-Dementia(s)/Cognitive impairment"
aria-checked="false" role="checkbox" tabindex="0" value="Dementia(s)/Cognitive impairment">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="otherHealthConditions-Dementia(s)/Cognitive impairment" class="Checkbox_text__1TGA3">Dementia(s)/Cognitive impairment</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-otherHealthConditions" type="checkbox" name="otherHealthConditions"
id="otherHealthConditions-Developmental condition (such as ADHD, Autism Spectrum Disorders, Down Syndrome and Dyspraxia)" aria-checked="false" role="checkbox" tabindex="0"
value="Developmental condition (such as ADHD, Autism Spectrum Disorders, Down Syndrome and Dyspraxia)">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="otherHealthConditions-Developmental condition (such as ADHD, Autism Spectrum Disorders, Down Syndrome and Dyspraxia)" class="Checkbox_text__1TGA3">Developmental condition (such as ADHD, Autism Spectrum
Disorders, Down Syndrome and Dyspraxia)</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-otherHealthConditions" type="checkbox" name="otherHealthConditions" id="otherHealthConditions-Mental health" aria-checked="false" role="checkbox"
tabindex="0" value="Mental health">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="otherHealthConditions-Mental health" class="Checkbox_text__1TGA3">Mental health</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Age related needs</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-ageRelatedNeeds" type="checkbox" name="ageRelatedNeeds" id="ageRelatedNeeds-Pensionable age" aria-checked="false" role="checkbox" tabindex="0"
value="Pensionable age">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="ageRelatedNeeds-Pensionable age" class="Checkbox_text__1TGA3">Pensionable age</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-ageRelatedNeeds" type="checkbox" name="ageRelatedNeeds" id="ageRelatedNeeds-Someone with a young child or children under the age of 5"
aria-checked="false" role="checkbox" tabindex="0" value="Someone with a young child or children under the age of 5">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="ageRelatedNeeds-Someone with a young child or children under the age of 5" class="Checkbox_text__1TGA3">Someone with a young child or children under the age of 5</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Temporary registration (such as a recent bereavement, divorce, redundancy, major surgery or stay in hospital)</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-temporaryRegistration" type="checkbox" name="temporaryRegistration"
id="temporaryRegistration-Temporary - Post hospital recovery (for example, recovering from medical treatment)" aria-checked="false" role="checkbox" tabindex="0"
value="Temporary - Post hospital recovery (for example, recovering from medical treatment)">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="temporaryRegistration-Temporary - Post hospital recovery (for example, recovering from medical treatment)" class="Checkbox_text__1TGA3">Temporary - Post hospital recovery (for example, recovering from
medical treatment)</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-temporaryRegistration" type="checkbox" name="temporaryRegistration"
id="temporaryRegistration-Temporary - Life changes (such as recent bereavement or redundancy)" aria-checked="false" role="checkbox" tabindex="0" value="Temporary - Life changes (such as recent bereavement or redundancy)">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="temporaryRegistration-Temporary - Life changes (such as recent bereavement or redundancy)" class="Checkbox_text__1TGA3">Temporary - Life changes (such as recent bereavement or redundancy)</label></span>
</div>
</div>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-temporaryRegistration" type="checkbox" name="temporaryRegistration" id="temporaryRegistration-Temporary - Young adult householder (<18)"
aria-checked="false" role="checkbox" tabindex="0" value="Temporary - Young adult householder (<18)">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="temporaryRegistration-Temporary - Young adult householder (<18)" class="Checkbox_text__1TGA3">Temporary - Young adult householder (<18)</label></span>
</div>
</div>
</fieldset>
</div>
</div>
</section>
</div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"><label class="Label_label__dVF3q FormField_label__SaPjx" for="homeVisitSecurityPassword">Home visit security password</label>
<div class="InputPassword_inputField__VAHCn"><input type="password" aria-describedby="error-homeVisitSecurityPassword" class="InputPassword_textInput__fOC4t" data-error="false" aria-label="Password" name="homeVisitSecurityPassword"
id="homeVisitSecurityPassword" role="input" value=""><button class="button undefined" data-appearance="blank" data-color="light" type="button" aria-label="Show password" aria-pressed="false"><svg viewBox="0 0 24 24"
class="Icon_icon__29ZJ9" aria-hidden="true" focusable="false" data-size="xs" fill="none" name="eye-hide" role="presentation">
<title></title>
<path d="M10.44 11.0499C9.56003 11.9299 9.56003 13.3499 10.44 14.2299C11.32 15.1099 12.74 15.1099 13.62 14.2299" stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
<path
d="M9.06002 5.1799C10.02 4.8999 11.02 4.7699 12.03 4.7699C16.53 4.7699 20.28 7.3899 23.28 12.6499C22.4 14.1799 21.47 15.4899 20.46 16.5699M18.05 18.6599C16.22 19.8999 14.21 20.5199 12.02 20.5199C7.52002 20.5199 3.77002 17.8999 0.77002 12.6399C2.31002 9.9499 4.05002 7.9399 5.98002 6.6299"
stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
<path d="M1.90991 2.5199L22.1499 22.7599" stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
</svg></button></div>
<div class="FormField_tooltip__udmVB">
<div class="FormTooltip_tooltip__w1CxM"><button class="FormTooltip_tooltipButton__EydVy" type="button" aria-expanded="false"><svg viewBox="0 0 24 24" class="Icon_icon__29ZJ9" aria-hidden="true" focusable="false" fill="none"
name="ico_help_blue">
<title></title>
<path d="M12.01 8.61V14.34" stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
<path
d="M3.25989 22.25H20.7699C22.1499 22.25 23.2599 21.09 23.2499 19.67C23.2499 19.35 23.1899 19.03 23.0699 18.73L14.1899 3.07C13.5199 1.83 11.9999 1.39 10.7899 2.07C10.3799 2.3 10.0399 2.65 9.80989 3.07L0.929893 18.73C0.409893 20.04 1.02989 21.53 2.30989 22.06C2.56989 22.17 2.83989 22.23 3.11989 22.24"
stroke-width="1.5" stroke-linecap="round" stroke-linejoin="round"></path>
<circle cx="12.02" cy="17.52" r="0.75" fill="currentColor"></circle>
</svg><span>Help</span></button></div>
</div>
</div>
</div>
</section>
</div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<h3 class="FormFieldset_formFieldTitle__SVUvX" role="group">How did you hear about us?</h3>
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<div class="react-select css-b62m3t-container"><span id="react-select-2-live-region" class="css-7pg0cj-a11yText"></span><span aria-live="polite" aria-atomic="false" aria-relevant="additions text" role="log"
class="css-7pg0cj-a11yText"></span>
<div class=" css-ulnysk-control">
<div class=" css-1dyz3mf">
<div class=" css-1k6j5ld" id="react-select-2-placeholder">Select...</div><input id="howDidYouHearAboutUs" tabindex="0" inputmode="none" aria-autocomplete="list" aria-expanded="false" aria-haspopup="true"
aria-label="howDidYouHearAboutUs" role="combobox" aria-activedescendant="" aria-readonly="true" aria-describedby="react-select-2-placeholder" class="css-1hac4vs-dummyInput" value="">
</div>
<div class=" css-2ljjj0"><span class=" css-196jqjz"></span>
<div class=" css-1xc3v61-indicatorContainer" aria-hidden="true"><svg height="20" width="20" viewBox="0 0 20 20" aria-hidden="true" focusable="false" class="css-8mmkcg">
<path
d="M4.516 7.548c0.436-0.446 1.043-0.481 1.576 0l3.908 3.747 3.908-3.747c0.533-0.481 1.141-0.446 1.574 0 0.436 0.445 0.408 1.197 0 1.615-0.406 0.418-4.695 4.502-4.695 4.502-0.217 0.223-0.502 0.335-0.787 0.335s-0.57-0.112-0.789-0.335c0 0-4.287-4.084-4.695-4.502s-0.436-1.17 0-1.615z">
</path>
</svg></div>
</div>
</div><input name="howDidYouHearAboutUs" type="hidden" value="">
</div>
</div>
</div>
</section>
</div>
<div class="FormPage_fieldsetItem__hJtZg">
<section class="FormPage_fieldsetItemInner__8yr0b">
<div class="FormFieldset_formFieldSets__8WDzh" aria-describedby="error-pleaseLetUsKnowYourReasonForRegisteringBySelectingAnyOfTheOptionsApplicableToYouOrAnyoneElseLivingInTheProperty">
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<h4 class="TitleAndDescription_heading__LR9CJ">Looking after your information</h4>
<p class="TitleAndDescription_description__i6gMv">To offer this service, we'll keep the information you have given us and only contact you to provide you with support during a power cut or to provide information about the Priority
Services Register or other essential services. Your personal information will not be used by us or our partners for marketing purposes, but we work with a range of support partners or other organisations that may contact you for
feedback about our service. You can update your information at any time. If you are completing this form on behalf of someone else, by completing it you confirm that you have the permission of that person to do so.</p>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz">
<fieldset class="FormField_fieldset__oKwcF">
<legend class="Legend_legend__5lEpg FormField_label__SaPjx">Would you like to receive priority support from your energy supplier (the company you pay your energy bills to) including their meter operators and your gas distribution
company? We may also be able to share your information with your water supplier to enable you to receive their priority support, depending on who your supplier is. Please tick this box if you are happy for us to pass your
information to your energy and water supplier (if your water company is part of our priority services collaboration).</legend>
<div class="FormField_checkboxListItem__gHwzF">
<div class="undefined Checkbox_checkbox__Leqt5 " data-is-variant="false">
<div class="Checkbox_tickBoxWrapper__Nb8FM undefined"><input aria-describedby="error-energySupplierPsr" type="checkbox" name="energySupplierPsr" id="energySupplierPsr-Yes" aria-checked="false" role="checkbox" tabindex="0"
value="Yes">
<div class="Checkbox_checkboxTick__v3C7H" data-error="false" tabindex="-1"></div>
</div><span><label for="energySupplierPsr-Yes" class="Checkbox_text__1TGA3">Yes</label></span>
</div>
</div>
</fieldset>
</div>
<div data-is-disabled="false" data-is-power-cut-checks="false" class="FormField_formField__9a2wz"></div>
</div>
</section>
</div>
</div>
</div>
<div class="DynamicForms_formControls__DUpiu">
<div class="DynamicForms_formButtons__tyls8" data-with-link="false"><button class="button undefined" data-appearance="NewPrimaryButton" data-color="light" type="submit"><span class="buttonLink" data-layout="ltr">Submit</span></button></div>
</div>
</form>Text Content
COOKIES We use necessary cookies to make our website work. You can only disable these by changing the settings in your browser, but this may affect how our website functions or displays on your device. We also use additional cookies. These help us to enhance your experience, for example, to personalise content, remember your preferences and improve our services. To make detailed changes to these, you can manage your preferences in the cookie settings. Accept additional cookiesReject additional cookiesCookie settings <iframe src="https://www.googletagmanager.com/ns.html?id=GTM-KPQW8SH" height="0" width="0" style="display:none;visibility:hidden"></iframe> Click4Assistance UK Live Chat Software PRIORITY SERVICES REGISTER - APPLICATION FORM Accessibility tool The Priority Services Register is free to join. It helps us to look after customers who have specific communication, access or safety needs. If you live in London, the South East or the East of England, we can offer extra support when you need it, for example if you experience a power cut. To be added to our Priority Services Register, please complete our short form below. If you would like to receive a copy of our Priority Services Register application form in large font, in EasyRead, or in Braille, please call 0800 169 9970 or email us at psr@ukpowernetworks.co.uk and we’ll be happy to arrange this for you. You can also download our EasyRead form and language forms from our Priority Services resources and downloads web page. For more information on how we will treat your personal data, please read our Privacy Policy and our Priority Services Promise. Mandatory questions Questions which have a star (*) after them are mandatory fields. You will not be able to complete the form without answering these. ADDRESS Address * Search WHO SHOULD WE CONTACT ABOUT THE PROPERTY DURING A POWER CUT? Title * First name * Last name * Preferred contact number * Alternative contact number Email address IS THERE ANYONE ELSE YOU WOULD LIKE US TO CONTACT DURING A POWER CUT? Title First name Last name Preferred contact number Alternative contact number Email address PLEASE LET US KNOW YOUR REASON FOR REGISTERING BY SELECTING ANY OF THE OPTIONS APPLICABLE TO YOU OR ANYONE ELSE LIVING IN THE PROPERTY* Rely on medical equipment that needs electricity and/or water Nebuliser and apnoea monitor Heart, lung and ventilator Dialysis, feeding pump and automated medication Oxygen concentrator Medically dependent showering/bathing Careline/telecare system Medicines requiring refrigeration Stair lift, hoist and electric bed Water dependent Would you like to have an additional, independent person present if our staff need to visit your property? Additional presence preferred Chronic/serious illness Yes Safety Oxygen Use Poor sense of smell/taste Poor mobility Physical impairment Unable to answer door Restricted hand movement Communication needs Blind Partially sighted Hearing impairment (including Deaf) Speech impairment Unable to communicate in English Other health conditions Dementia(s)/Cognitive impairment Developmental condition (such as ADHD, Autism Spectrum Disorders, Down Syndrome and Dyspraxia) Mental health Age related needs Pensionable age Someone with a young child or children under the age of 5 Temporary registration (such as a recent bereavement, divorce, redundancy, major surgery or stay in hospital) Temporary - Post hospital recovery (for example, recovering from medical treatment) Temporary - Life changes (such as recent bereavement or redundancy) Temporary - Young adult householder (<18) Home visit security password Help HOW DID YOU HEAR ABOUT US? Select... LOOKING AFTER YOUR INFORMATION To offer this service, we'll keep the information you have given us and only contact you to provide you with support during a power cut or to provide information about the Priority Services Register or other essential services. Your personal information will not be used by us or our partners for marketing purposes, but we work with a range of support partners or other organisations that may contact you for feedback about our service. You can update your information at any time. If you are completing this form on behalf of someone else, by completing it you confirm that you have the permission of that person to do so. Would you like to receive priority support from your energy supplier (the company you pay your energy bills to) including their meter operators and your gas distribution company? We may also be able to share your information with your water supplier to enable you to receive their priority support, depending on who your supplier is. Please tick this box if you are happy for us to pass your information to your energy and water supplier (if your water company is part of our priority services collaboration). Yes Submit