Meals Are Delivered Between 11.30Am and 2Pm, 7 Days a Week, 365 Days a Year
Please return this form to:
Call0330 2000 103for any queries
Visit for more information
Meals are delivered between 11.30am and 2pm, 7 days a week, 365 days a year.
We can deliver to any address in Hertfordshire and all our prices include delivery.
Hot meal and dessert: £4.55
Tea meal (Sandwich, Roll, or Cream tea; and a snack; dessert; and a drink): £3.25
Breakfast (Cereal or Porridge with milk; pastry or snack;and a drink): £2.75
You can only order a tea meal or breakfast if you are also having a hot meal.
ELIGIBILITYAnyone can receive a meal; however, the price will be £4.55 if they meet any oneof the below criteria.
1. Does the client have difficulty in preparing or cooking a meal because:
They are frail, confused, or housebound? / ☐ /
They have a mental, physical, and/or learning disability? / ☐ /
They would be at risk in preparing a meal? / ☐ /
2. Is the client unable to shop regularly for food or obtain a meal from any other source? / ☐ /
3. Does the person need temporary cover or service because:
Their carer is unwell or on holiday? / ☐ /
They are suffering bereavement, illness, or have recently been discharged from hospital? / ☐ /
CLIENT’S DETAILS (PERSON RECEIVING THE MEALS)
Title / Forename
Surname / Gender / Male ☐Female ☐
House/Flat number / Address
Town / Postcode
Date of Birth / Telephone (inc area code)
GP Surgery
GP Telephone
We are required for monitoring purposes to collect the ethnicity of all our clients to ensure the equality of our service:
White: British / ☐ / White: Other / ☐ / Chinese / ☐ /Mixed: White and Black Caribbean / ☐ / Mixed: White and Black African / ☐ / Mixed: White and Asian / ☐ /
Mixed: Other / ☐ / Indian / ☐ / Pakistani / ☐ /
Bangladeshi / ☐ / Other Asian / ☐ / Caribbean / ☐ /
African / ☐ / Other Black / ☐ / Does not wish to disclose / ☐ /
REFERRER’S (YOUR) DETAILS
Full name
Role or relationship to client
Organisation (if applicable)
Telephone
DELIVERY AND ACCESS DETAILS
Key safe code / Door entry code (for main building)
Key safe location
Any other information (for instance, if the house is hard to find)
Is there anything that could pose a risk to our staff when delivering?
MEALS ON WHEELS SERVICE DETAILS
Start date / End date(only required if meals are needed for a short time)
Please select the days that a hot meal and dessert is required (£4.55 per day):
Meals are required every day / ☐ /OR
Mon / ☐ / Tue / ☐ / Wed / ☐ / Thurs / ☐ / Fri / ☐ / Sat / ☐ / Sun / ☐ /Tea meals and breakfasts(can only be ordered with hot meal)
Tea(£3.25) / Mon / ☐ / Tue / ☐ / Wed / ☐ / Thurs / ☐ / Fri / ☐ / Sat / ☐ / Sun / ☐ /Breakfast(£2.75) / Mon / ☐ / Tue / ☐ / Wed / ☐ / Thurs / ☐ / Fri / ☐ / Sat / ☐ / Sun / ☐ /
Please tick here if the client would like frozen meals to cook themselves (we’ll arrange delivery with the client directly). Please note, an oven is best for cooking our meals, but a microwave can work too: ☐
CLIENT WELLBEINGPlease tick the box below if there is anything that we may need to be aware of with regards to the client:
Has poor mobility / ☐ / Slow to answer the door / ☐ / Is confused / ☐ /Visual impairment / ☐ / Hearing impairment / ☐ / Speech impairment / ☐ /
Has dementia / ☐ / Could the client be violent? / ☐ / English not their first language / ☐
Is there anything else we may need to know about the client?
Will the client need our staff to do any of the following when delivering the meal?
Remove lids / ☐ / Plate meal / ☐ / Encourage to eat / ☐ / Get cutlery / ☐ / Cut up meal / ☐ /HEALTH AND NUTRITION
To ensure that the client receives appropriate meals, please complete this section to tell us about their likes and dislikes, any allergies, health conditions, or nutritional issues.
Please indicate any important likes and dislikes below:Client particularly likes: / Client particularly dislikes:
Please indicate any allergiesbelow:
Celery / ☐ / Cereals/Gluten / ☐ / Sesame Seeds / ☐ / Eggs / ☐ / Fish / ☐ / Lupin / ☐ / Peanuts / ☐ /
Molluscs / ☐ / Mustard / ☐ / Crustaceans / ☐ / Milk / ☐ / Nuts / ☐ / Soya / ☐ / Sulphites / ☐ /
Please indicate any dietary preferences below:
Heart healthy (meals low in saturated fat & reduced salt) / ☐ / Gluten Free / ☐
Higher energy (main meals contain at least 400 calories and desserts at least 300 calories) / ☐ / Desserts that contain less than 15g of sugar * / ☐
Vegetarian / ☐ / Vegan / ☐ / Caribbean/West Indian / ☐ / Kosher / ☐ / Asian Halal / ☐
*PLEASE NOTE: If the client has diabetes, all of our meals are suitable; however, they may wish to select heart healthy meals or desserts that contain less that 15g of sugar.
If the client requires texture modified meals**, please indicate which texture is required, and indicate the reason for this:**PLEASE NOTE: we are currently unable to provide texture modified tea and breakfast meals.
NeedsThick puree (Texture C) due to swallow issue (as advised by Speech & Language Therapist) / ☐ / Wants Thick puree (Texture C) as a preference (no swallow concern) / ☐NeedsSoft/Pre-mashed (Texture D) due to swallow issue (as advised by Speech & Language Therapist) / ☐ / Wants Soft/Pre-mashed (texture D) as a preference (no swallow concern) / ☐
NeedsFork mashable (Texture E) due to swallow issue (as advised by Speech & Language Therapist) / ☐ / Wants Fork mashable (texture E) as a preference (no swallow concern) / ☐
Please tick the box if the client has any health conditions that may be relevant to the client’s nutritional requirements:
Dementia / ☐ / Poor appetite / ☐ / Complex diet / ☐ / Losing weight unintentionally / ☐ /
Dysphagia / ☐ / Heart condition / ☐ / Diabetes / ☐ / Chewing issues / ☐ /
Underweight / ☐ / Overweight / ☐ / Kidney disease / ☐ / Swallowing issues / ☐ /
Other (please specify):
Would this person benefit from a nutrition and wellbeing check? ***
If yes, please ensure a reason for the visit is selected from the list above. / Yes
☐ / No ☐
*** A member of our Nutrition & Wellbeing Team can visit to discuss the client’s health and nutrition with them, assess their current nutritional status, and measure their risk of malnutrition
EMERGENCY CONTACTSIt is very important that two emergency contacts are provided who are available to answer the phone between 11.30am and 2pm if required. Where possible please provide a mobile number.
Emergency contact 1Name
Address
Post Code
Relationship to client
Telephone (Mob)
Telephone (Home)
Key Holder? / Yes ☐ No ☐
Emergency contact 2
Name
Address
Post Code
Relationship to client
Telephone (Mob)
Telephone (Home)
Key Holder? / Yes ☐ No ☐
If the client receives home care, then please list the contact details of the organisation providing this:
Name of organisation
Telephone number
If the client has a community alarm, then please list the contact details of the organisation providing this:
Name of organisation
Telephone number
PAYMENT
We will send a bill at the end of the month that can be paid by Direct Debit, credit or debit card over the telephone, cheque, Postal Order, or an Allpay card. We can never accept cash.
Preferred payment methodIf someone other than the client is paying for the meal, please list their details here:
Name / TelephoneRelationship to client
Address
OTHER SERVICES
As well as meals on wheels, HILS also delivers a number of other services to help people remain happy, healthy, and independent in their home. If the client is interested in any of our other services, please tick below and our Support Team will get in touch.
Dementia clubs and activities / ☐ / Medication prompts / reminders **** / ☐Community Alarm and Telecare installation
(in partnership with Hertfordshire Careline) / ☐ / Home visit from an Optician / ☐
****PLEASE NOTE: we can only accept referrals for medication prompts from a health or social care professional, such as a social worker, GP, or similar person who can confirm that the client has the capacity to manage, dose, and self-administer their medication.
Hertfordshire Independent Living Service keeps data secure in accordance with the Data Protection Act 1998. We will never pass on details for marketing or sales. Data will only be used for the purposes of providing HILS’ services to the client.
Please return this form to: