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EyEagle Home Safety Assessment Form

EyEagle helps families reduce bathroom fall risks and get faster help during emergencies. Share your details and our team will contact you for a safety check or product explanation

Your Name*

Please enter a valid full name

Phone Number / WhatsApp No.*

Please enter a valid 10-digit mobile number

Site name or location

Who are you considering EyeEagle for?*

Senior parent / grandparent living in the same homeSenior parent / grandparent living awaySomeone recovering from illness or surgeryPregnant family memberPerson living aloneMyselfGeneral home safetyOther

Please select at least one option

What is your main safety concern?*

Bathroom slips or fallsNo one nearby during emergencyElderly person alone at homeNight-time bathroom useNeed bathroom grab bars / supportNeed emergency alert systemNot sure, just exploring

Please select at least one option

Any immediate safety concern?*

YesNo

Brief description of concern

What would you like next?*

Book a bathroom safety assessmentUnderstand the EyeEagle safety kitGet pricing detailsJust share information for now

Preferred time to contact

TomorrowDay After TomorrowThis weekend

Timings

MorningAfternoonEvening

I agree to be contacted about this request.*REQUIRED

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