Online Referral Form

This form MUST only be filled in and submitted by referral agents.

Please read the Referral Terms before filling in the form. You will be required to agree to these terms before the information can be submitted.

Should you require an item not on the list then please contact the office before submitting the form and enter the details discussed in the ‘Other Information’ box below.

Please fill in the details in the boxes or select, as required.  An asterisk denotes a required field. When completed, please click the send button. If there are any omitted required fields, you will be prompted to fill them in before clicking the send button again. Once successful, a confirmation will display on screen and an email will be sent to the Roundabout office. A copy will be sent to the referral agent’s email address, if supplied. Please ensure all details are entered correctly.

Referral Agency and Client Details

Referral Agency Client
Title*
Agency* Name*  
Address* 1  
2  
3  		 Address* 1  
2  
3  
Town*   Town*  
County* County*
Postcode*   Postcode
(reqd. if known)		  
Referral Agent Phone
(reqd. if known)		  
Name*   Mobile
(reqd. if known)		  
Dept.   Email  
Phone*   Notes
Mobile  
Email
(reqd. if available)		  

 

Miscellaneous Data

Who is to pay the charges?*   
Age of Client (select one):    16-25 26-50 51-64 65+
No. of Children:  0-3 years    4-10 years    11-15 years 
Type of Premises* (select one)   House Flat Bungalow Bedsit Caravan
Stairs*  
Housing Association Name   

 

Furniture Required

Please remember to take into account stair access and room size when requesting larger items such as wardrobes and settees.

Item £ Qty Item £ Qty Item £ Qty
Double Bed Base £9   Cot
(incl. mattress if in stock)		 £5   Desk    (Select type)
 Computer  Writing 		£5  
Double Bedding £7   High Chair £2   Rug  (Specify size below) £4  
Double Headboard £1   Settee (3 seater) £20   Dining Table £14  
Double Mattress £9   Settee (2 Seater) £18   Dining Chair (each) £3  
Single Bed Base £7   Armchair
(matching where possible)		 £8   Kitchen Table £10  
Single Bedding £6   Fireside Chair
(Specify size below)		 £7   Kitchen Chair (each) £3  
Single Headboard £1   Recliner Chair £7   Kitchen Starter Pack £10  
Single Mattress £7   Sideboard £5   Ironing Board £3  
Bunk Bed (2 Tier)
(inc. mattress if in stock)		 £18   Wall Unit £7  
Curtains £2 per pair
Qty WINDOW Width
(State cm or ins)		 WINDOW Height
(State cm or ins)
     
     
     
Chest of Drawers £7   Bookcase £5  
Wardrobe (Select size)
 Large  Small 		£10   Occasional Table £4  
Bedside Cabinet £4   TV Cabinet/Stand £4  
Dressing Table £3   CD Storage Unit £1  
Other Information:
(i.e. Additional Items and Special requirements; e.g. Rug size(s); Fireside Chair Height to Seat & Depth)

 

captcha
In the box below, please enter the numbers and/or letters in the box above in the same order as you see them
 

Tick to confirm you have read and accept our Referral Terms   

Click this button to send the data as an email
(this is only possible after acceptance of our terms)      

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