Form progress: 0% - Page 1 of 5 If you would like to apply for a lifeline alarm system, please use this form to provide us with your personal details. Once you have submitted the form we will contact you to arrange a home visit. If you have any queries or would like to discuss the service please contact the lifeline team. Please read the terms and conditions of the lifeline alarm service agreement. You will be given a copy of this agreement to sign when your lifeline alarm is installed. Please note: for this service you will need a modern telephone point which is situated next to a 13 amp electrical socket on the same wall. Save and continue Complete this form later If you have registered with our website and are signed in, you can leave a form at any time to complete later. You can also view all of your saved and completed forms from your account page.