Virtual Assessment Request Form

Adapted assessment delivered through video technologies during the Covid-19 lockdown

If you have booked a Virtual Assessment and would now like to arrange for the virtual assessment to be carried our for yourself, or other member of staff *, please complete the form below and we will be in touch to schedule a suitable appointment time.

* IMPORTANT NOTICE: By completing this form you confirm that you have consent to share any 3rd party personal information under the latest Data Protection regulations. HWS undertake to protect your details in line with our Privacy Policy. If you wish to share health or other detailed information, please send separately in a password protected file. Thank You.

Requester's details

Please enter details for the person making the request - i.e. you.

Full Name *

Organisation Name *

Telephone Number *

Email Address *

Confirm Email Address *

Job Title *

Manager or Budget Holder *

Yes No

Please enter details of the authorised person(s) for secure receipt of personal information

Send assessment report to

Email Address

Telephone Number

For regular account holders, this may have been pre-agreed.

We can supply a copy of the assessment to a second authorised person - e.g. HR Dept., H&S

Copy report to

Email Address

This is optional. Leave blank if not required.

To be Assessed

Details about the person to be assessed and their location

Full Name *

Location (address)

Postcode

Telephone Number *

Email Address *

Job Title

Appointment Booking

Video Apps Available

Reason For Booking

All information submitted is processed in accordance with our Privacy Policy.

Beth, Student

Perfect service from start to finish. Jan was friendly and helpful when she assessed me at home and Phill was equally as helpful and knowledgeable when he delivered the equipment in a very quick turn around time. A very personable experience. On a different level to experiences I have had in the past with similar companies. The equipment fits perfectly and is going to make a massive difference for my working with my chronic condition. Would definitely return and recommend.

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