Dementia Safeguarding Wristband referral form

The Dementia Wristband scheme is a pilot scheme in which a wearable wristband is available free of charge to residents within the Swindon and Wiltshire area.

If you live with dementia, or are a carer or relative of someone with dementia or awaiting diagnosis, you can request a wristband which stores electronic information about the wearer such as their name and next of kin. The device can be scanned by emergency services, or by a person assisting them, if the individual is found lost or in distress.

The information you provide here will go to Alzheimer’s Support. A member of the team will be in touch very soon.

As this is currently a pilot, we would ask that you also complete the additional details about the wearer of the wristband in order to help us evaluate the effectiveness of the scheme. If the scheme is successful, this data will also be vital in ensuring future funding is committed to continuing the service.

About you
Who will be wearing the band?
Please chose one option that best describes the ethnic group or background of the wearer

By completing this form I consent to my information being recorded by Alzheimer’s Support for this purpose. If completed by a third party, I confirm that I have obtained consent from the person living with dementia, or have been granted power of attorney to act on their behalf.