INFORMATION FOR YOUR SYSTEM PERSONALIZATION CALL:
Your Name___________________________________________________________________
Address_______________________________________State________Zip code___________
Ph#________________Ph#______________Email____________________________________
Name of user if not you_________________________________________________________
and address where to be installed________________________________________________
City___________________________________State______________Zip code_____________
Name of Primary Care Dr. ___________________________________Ph#_________________
Preferred Hospital__________________________________City________________________
Responsible parties to notify in case of emergency (list up to three)
1. Name_____________________________________________Ph#______________________
Email Address________________________________________Relationship________________
2. Name_____________________________________________Ph#______________________
Email Address________________________________________Relationship________________
3. Name_____________________________________________Ph#______________________
Email Address________________________________________Relationship________________
We will identify if any responsible parties have a key to your residence, and whether you have a lockbox and associated code for entry to the home by responders during an emergency, we’ll do a brief health overview. identify any critical information about health or allergies responders or TeleCare nurses should know, and we'll designate specific health monitoring devices such as blood pressure cuff, weight scale, pulse oximetry device, glucose meter or other needed vital monitoring device.