Register for Shopmobility

Title *

Customer Name *

Email Address *

Address

Town

Postcode

Telephone number *

Date of arrival

Month

Day

Year

Estimated time of arrival

Hour

:

Minute

Estimated time of departure

Hour

:

Minute

Proof of ID?

Driving Licence

Bank Card

Other

Equipment required?

3 Wheel Scooter

4 Wheel Scooter

Wheelchair

Electric Wheelchair

Medical Details

Please state the nature of your restricted mobility and any other relevant conditions that may effect the use of equipment:

Right or left handed?

Right

Left

Do you have use of your thumbs?

Yes

No

Weight?

Under 18st

Over 18st

Do you have good eyesight?

Yes

No

Height

How did you hear about Shopmobility?

I agree:

Not to leave the vehicle unattended unless safely parked and locked
To ensure that the vehicle is used with due care and attention
Not to carry others whilst the vehicle is in my care
To return the vehicle in good condition at the time agreed
To reverse and manoeuvre around the centre with due care and attention
To acknowledge that vehicles do not have the right of way
That I have been instructed in the safe use of the vehicle
That I accept responsibility for my own safety and belongings
That the powered vehicles are switched off when not in use
That I have not been diagnosed as suffering from any condition that would prevent me from operating the powered vehicles
That powered vehicles should not be used under the influence of alcohol or illegal drugs
In the event of any damage being caused whilst using the equipment, I accept that I am liable for paying for the repairs

I agree: *

Click the checkbox to agree to these conditions.

By clicking here you provide your agreement to the above terms and your explicit consent for the processing of sensitive health data as you have recorded above.

You do not need to provide sensitive health data to access the shopmobility services through this form, and you can discuss your requirements directly with us instead.

The information is collected to ensure that we provide the shopmobility service that best meets your requirements.

Where you have provided this information, this data will be safeguarded and deleted after it is no longer required – usually once you have finished using our shopmobility service.

Land Securities Properties Limited is the data controller for your information and for more information about your rights, please visit our privacy page on https://landsec.com/policies/privacy-policy/visitors

Register for Shopmobility

Please complete the form below to request a Shopmobility reservation.