Request a Visit

Request a Visit If you would like to arrange a visit from one of our Volunteers please complete the form below.

Your form will be automatically sent to our Volunteer Visitor Supervisor who will make all of the necessary arrangements for your visit and may be in touch with you directly if necessary.

If you would like to speak to our Volunteer Visitor Supervisor please call 0845 2300 025 or email board.limblessassociation@yahoo.co.uk

Request a VV

Please enter today's date *

/ /

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?

Yes
No

Details of the Person Wishing to be Visited

Title *

First Name *

Surname *

Address line 1 *

Address line 2

Address line 3

Town *

County

Postcode *

Telephone number *
please provide the best contact number for our volunteer to call

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? *
If "No" you can skip to the last question and then submit

Yes
No

Reason for limb-loss

Type of surgery / limb-loss

Date 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

* Denotes required field.