Environment & health

Lifeline cancellation form

Contact Us

Who is completing this form?

Service user
Representative

If representative is completing on behalf of the Service User, please confirm your identity including name and relationship to the Service User:

If representative is completing, please indicate (if appropriate) that the Service User is aware that this notification is being given:

Yes - Service User is aware that I am giving notice to end the Lifeline service
No

Service user details

Title

First name(s)

Surname

Date of birth

House name/number

Street

Town

County

Postcode

Service user telephone number

Service user mobile phone number

Service user Email

Reason for cancellation

Feedback

Notice Period

Consent for storing submitted data

Yes, I give permission to store and process my data and agree to the Privacy notice

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