clickandpost.northerncarealliance.nhs.uk Open in urlscan Pro
81.201.130.231  Public Scan

Form analysis
1 forms found in the DOM

POST /Contact/Submit

<form action="/Contact/Submit" id="clickandpost" method="post" novalidate="novalidate"><input name="__RequestVerificationToken" type="hidden"
    value="qqxn7V2vyH6RtnrXh72o67DXIykjulY1dQpho8LaO70tD3XwGOr2ZUbjuffjZwH2_CQh3RhLo7k4Eu4VQZUkbsHi43gDHQ4CftX86owvA4A1">
  <fieldset>
    <legend class="legend">
      <span class="legend__number">1.</span>
      <span class="legend__title">Your details</span>
    </legend>
    <div class="row">
      <div class="form-group  col-md-6">
        <div class="row">
          <div class="col-md-12">
            <label for="FirstName"> First name <i class="fa  fa-asterisk  text-danger"></i>
            </label>
          </div>
          <div class="col-md-12">
            <input class="form-control" data-val="true" data-val-required="Please enter your first name." id="FirstName" name="FirstName" placeholder="First name" type="text" value="">
            <span class="field-validation-valid" data-valmsg-for="FirstName" data-valmsg-replace="true"></span>
          </div>
        </div>
      </div>
      <div class="form-group  col-md-6">
        <div class="row">
          <div class="col-md-12">
            <label for="LastName"> Last name <i class="fa  fa-asterisk  text-danger"></i>
            </label>
          </div>
          <div class="col-md-12">
            <input class="form-control" data-val="true" data-val-required="Please enter your last name." id="LastName" name="LastName" placeholder="Last name" type="text" value="">
            <span class="field-validation-valid" data-valmsg-for="LastName" data-valmsg-replace="true"></span>
          </div>
        </div>
      </div>
    </div>
    <div class="row">
      <div class="col-md-6  form-group">
        <div class="row">
          <div class="col-md-12">
            <label for="TelephoneNumber"> Telephone number <i class="fa  fa-asterisk  text-danger"></i>
            </label>
          </div>
          <div class="col-md-12">
            <input class="form-control" data-val="true" data-val-required="Please enter your telephone number." id="TelephoneNumber" name="TelephoneNumber" placeholder="Telephone number" type="text" value="">
            <span class="field-validation-valid" data-valmsg-for="TelephoneNumber" data-valmsg-replace="true"></span>
            <small class="form-text" id="TelephoneNumberHelp">Don't worry, we'll never share your email with anyone else.</small>
          </div>
        </div>
      </div>
      <div class="col-md-6  form-group">
        <div class="row">
          <div class="col-md-12">
            <label for="DateOfBirth"> Date of birth <i class="fa  fa-asterisk  text-danger"></i>
            </label>
          </div>
          <div class="col-md-12">
            <input class="form-control hasDatepicker" data-val="true" data-val-required="Please enter your date of birth." id="DateOfBirth" name="DateOfBirth" placeholder="dd/mm/yyyy" type="text" value="" maxlength="10">
            <span class="field-validation-valid" data-valmsg-for="DateOfBirth" data-valmsg-replace="true"></span>
          </div>
        </div>
      </div>
      <div class="col-md-6  form-group">
        <div class="row">
          <div class="col-md-12">
            <label for="Address"> Address <i class="fa  fa-asterisk  text-danger"></i>
            </label>
          </div>
          <div class="col-md-12">
            <textarea class="form-control" cols="20" data-val="true" data-val-required="Please enter your address" id="Address" name="Address" placeholder="Address" rows="3"></textarea>
            <span class="field-validation-valid" data-valmsg-for="Address" data-valmsg-replace="true"></span>
            <small class="form-text" id="emailHelp">This should be your full address including your postcode.</small>
          </div>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset>
    <legend class="legend">
      <span class="legend__number">2.</span>
      <span class="legend__title">Your requirements</span>
    </legend>
    <div class="row">
      <div class="form-group  col-md-12">
        <div class="row">
          <div class="col-md-12">
            <label for="Consumables"> Consumables required <i class="fa  fa-asterisk  text-danger"></i>
            </label>
          </div>
        </div>
        <div class="checkbox_list">
          <div class="row">
            <div class="col-sm-12 ">
              <input class="custom-control-input" id="ConsumablesRequired0" name="Consumables" type="checkbox" value="Tubing">
              <label class="custom-control  custom-checkbox" for="ConsumablesRequired0">
                <span class="custom-control-indicator"></span>
                <span class="custom-control-description">Tubing</span>
              </label>
            </div>
            <div class="col-sm-12 ">
              <input class="custom-control-input" id="ConsumablesRequired1" name="Consumables" type="checkbox" value="Batteries">
              <label class="custom-control  custom-checkbox" for="ConsumablesRequired1">
                <span class="custom-control-indicator"></span>
                <span class="custom-control-description">Batteries</span>
              </label>
            </div>
            <div class="col-sm-12 ">
              <input class="custom-control-input" id="ConsumablesRequired2" name="Consumables" type="checkbox" value="Tubing cleaning wire">
              <label class="custom-control  custom-checkbox" for="ConsumablesRequired2">
                <span class="custom-control-indicator"></span>
                <span class="custom-control-description">Tubing cleaning wire (suitable for thin tubes and open domes only, not moulds)</span>
              </label>
            </div>
            <div class="col-sm-12 ">
              <input class="custom-control-input" id="ConsumablesRequired3" name="Consumables" type="checkbox" value="Wind filters">
              <label class="custom-control  custom-checkbox" for="ConsumablesRequired3">
                <span class="custom-control-indicator"></span>
                <span class="custom-control-description">Wind filters (Rochdale only)</span>
              </label>
            </div>
            <div class="col-sm-12 ">
              <input class="custom-control-input" id="ConsumablesRequired4" name="Consumables" type="checkbox" value="Wax guards">
              <label class="custom-control  custom-checkbox" for="ConsumablesRequired4">
                <span class="custom-control-indicator"></span>
                <span class="custom-control-description">Wax guards (ITE aids only)</span>
              </label>
            </div>
          </div>
        </div>
        <span class="field-validation-valid" data-valmsg-for="Consumables" data-valmsg-replace="true"></span>
      </div>
    </div>
    <div class="row">
      <div class="col-md-6  form-group">
        <div class="row">
          <div class="col-md-12">
            <label for="AreaIssuedHearingAids"> Area issued hearing aids <i class="fa  fa-asterisk  text-danger"></i>
            </label>
          </div>
        </div>
        <div class="row">
          <div class="col-md-12">
            <select data-val="true" data-val-required="Please select the area who issued your hearing aids." id="AreaIssuedHearingAids" name="AreaIssuedHearingAids" style="width: 100%;" tabindex="-1" class="select2-hidden-accessible"
              aria-hidden="true">
              <option value="">Please Select</option>
              <option value="Bury">Bury</option>
              <option value="Oldham">Oldham</option>
              <option value="Heywood, Middleton and Rochdale">Heywood, Middleton and Rochdale</option>
            </select><span class="select2 select2-container select2-container--default" dir="ltr" style="width: 100%;"><span class="selection"><span class="select2-selection select2-selection--single" role="combobox" aria-haspopup="true"
                  aria-expanded="false" tabindex="0" aria-labelledby="select2-AreaIssuedHearingAids-container"><span class="select2-selection__rendered" id="select2-AreaIssuedHearingAids-container" title="Please Select">Please Select</span><span
                    class="select2-selection__arrow" role="presentation"><b role="presentation"></b></span></span></span><span class="dropdown-wrapper" aria-hidden="true"></span></span>
            <span class="field-validation-valid" data-valmsg-for="AreaIssuedHearingAids" data-valmsg-replace="true"></span>
          </div>
        </div>
      </div>
    </div>
  </fieldset>
  <fieldset>
    <legend class="legend"></legend>
    <div class="row">
      <div class="col-md-6  form-group">
        <div class="row">
          <div class="col-md-12">
            <label class="label--large_content" for="EmailAddress"> We value your feedback. Please enter your email address if you would be happy to receive a questionnaire about your experience of click and post </label>
          </div>
          <div class="col-md-12">
            <input class="form-control" id="EmailAddress" name="EmailAddress" placeholder="Email address" type="text" value="">
            <span class="field-validation-valid" data-valmsg-for="EmailAddress" data-valmsg-replace="true"></span>
            <small class="form-text" id="EmailAddressHelp">Don't worry, we'll never share your email with anyone else.</small>
          </div>
        </div>
      </div>
    </div>
  </fieldset>
  <div class="sr-only">
    <input id="AreYouABot" name="AreYouABot" type="text" value="">
  </div>
  <button class="btn  btn-primary" type="submit">
    <span>Submit</span>
    <i class="fa  fa-chevron-right"></i>
  </button>
</form>

Text Content

Get Started


CLICK AND POST SERVICE

We are always working hard to improve our services.

We are pleased to be able to offer our patients a Click and Post Service,
meaning we can deliver hearing aid accessories straight to your door by post.
This includes things like batteries and tubing.

All you need to do is fill out the form below and click submit. Your form will
be sent to the team and we will post your accessories out to you within one
week.

PLEASE NOTE:

Before using Click and Post you need to be set up on the system. To do this,
please speak to a member of the team at your next appointment, or contact your
local audiology team: 01706 674 913

We only send consumables when they are due (every four to six months for tubes).
If we receive a request before we may contact you in relation to this.

Please complete the form below.

denote required fields.

1. Your details
First name

Last name

Telephone number
Don't worry, we'll never share your email with anyone else.
Date of birth

Address
This should be your full address including your postcode.
2. Your requirements
Consumables required
Tubing
Batteries
Tubing cleaning wire (suitable for thin tubes and open domes only, not moulds)
Wind filters (Rochdale only)
Wax guards (ITE aids only)
Area issued hearing aids
Please Select Bury Oldham Heywood, Middleton and Rochdale Please Select
We value your feedback. Please enter your email address if you would be happy to
receive a questionnaire about your experience of click and post
Don't worry, we'll never share your email with anyone else.

Submit
©2021 Click and Post Service