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Quality Retirement Homes

Contact Us

Please contact us if you need help reading this form, or if you would like any part of it translating.

Please note that regretfully we do not allow pets

Applicant 1 (MUST be aged 55 or over)













Applicant 2













(Please tick the relevant boxes below)

 I am interested in living at Upwell Park I am interested in living at Wheel Centre I am interested in living at Elliott Lodge I have no preference

MEDICAL HISTORY

Please provide us with a brief outline of your medical history, including any current medication that you may be taking.

Applicant 1

Applicant 2

Are you currently receiving Attendance Allowance (or Disability Living Allowance/PIP if under the age of 65)?

 Yes No

If YES, who receives this?

 Applicant 1 Applicant 2

Do you anticipate that you will need to claim Housing Benefit to assist with your rent payments?

 Yes No

Do you currently receive Pension Credit

 Yes No
If YES, is this:
 Guaranteed Pension Credit Saving Pension Credit

I / We understand that the completion of this Expression of Interest form does not necessarily mean that
I / We will be placed on a waiting list or offered accommodation.

Signed by applicant 1*

Date

Signed by applicant 2

Date

*Please note that by clicking submit on this form you are acknowledging the terms displayed above & understand that the submission will be considered as acceptance.

If you would like to add any medical information to your application, please do so below:

Applicant 1

Applicant 2

Thank you for your time.
We will contact you when a suitable vacancy arises. We regret that we are unable to estimate how long you are likely to be waiting.

**The information you have supplied will be treated in the utmost confidence and will not be stored on any computer system**