To be completed if you are making this request on behalf of someone else:

Please enter your name and relationship to the person wishing to be visited

Please enter your email address or contact number in case we need to get in touch with you for further details

Has consent been given by the person wishing to be visited?


Details of the Person Wishing to be Visited:

Title*

First name*

Last name*

Address line 1*

Address line 2

Address line 3

Town*

County*

Postcode*

Telephone number

Best time to call

Email address*

Date of birth

Current LA membership status?


Details of Limb-Loss:

Please help us to find the most suitable Volunteer by providing the following information.

Has the amputation already occured?

Reason for limb-loss

Type of surgery / limb-loss

Date of limb-loss

Level of limb-loss

Which Limb Centre do you attend?

If other, please state

Please give a brief reason why you would like to see a VV or tell us about any specific areas you would like to discuss.
This will help us to find the best volunteer for you: