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- formerly the Disabled Living Centre
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About
Enquiry Form
Please note:  *  denotes essential information required.
Otherwise, complete the form where possible or as appropriate.
Remember to click the submit button when you have completed the form.
 
 
 
 
* Name:
* Sex:
female
male
* First Line Address:
Remainder Address:
* Postcode:
* Contact Telephone:
Email Address:
Subject:
General
Beds
Chairs
Children's Equipment
Clothing Service
Communication
Continence
Driving
Driving Assessment
Driving Equipment
Eating & Drinking
Gardening
Hoisting & Lifting
Household Equipment
Leisure & Sport
Manual Wheelchairs
Office Furniture
Organisations
Other Subject
Personal Care
Powered Vehicles
Pressure Relief
Telephones & Alarms
Transport Passenger
Walking Aids
* Impairment:
Physical
Learning Difficulties
Mental Health
Multiple
None
Other
Refused Information
Unknown
Sensory
* Ethnic Origin:
White (UK)
White (European)
White (Other)
Black (UK)
Black (African/Caribbean)
Black (South Asian)
Black (Other)
Other
Refused Information
Unknown
* Age Group:
Unknown
0 - 4
5 - 14
15 - 18
19 - 24
25 - 40
41 - 59
60 - 64
65 - 74
75+
* How Heard:
Unknown
Been Before
GP Practice/Doctor
Friend/Relative
Media/Publications
Social Worker/Social Services Dept
Retailer
Voluntary Organisation
Health Organisation
Other
District:
Bristol
North Somerset
Somerset
Bath & NE Somerset
South Gloucestershire
Gloucestershire
Wiltshire
Other
Unknown
* Enquiry Description:
*
Genuine request validation:
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LivingBristol