WHO IS COMPLETING THIS ORDER FORM? *

Watch Recipient/ Participant

Case Manager/ Care Coordinator

Messaging Packages (Select up to 3)

Isolation Messaging

Healthy Eating Messaging

Mental Health Messaging

Medication Messaging

Laughter is the Best Medicine Messaging

Active Living

WHO IS THIS WATCH FOR? *

Please Complete Watch Recipient / Participant

First Name

Last Name

Wearer Phone *

(###)

###

####

Would the participant like to access the online user portal? *

Uer portal displays activity history (steps, heart rate) and watch status.

Yes - please enter participant Email address below

No

Date of Birth *

MM

DD

YYYY

Physical Address (no PO Box) *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is Shipping Address same as Physical Address?

Yes - skip down to Emergency Contact section

No - please enter below

Shipping Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

EMERGENCY CONTACT INFORMATION (for PERS) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Optional 2nd Emergency Contact:

First Name

Last Name

Phone

(###)

###

####

Do you have a Legal Guardian?

Yes - same as Emergency Contact

Yes - different from Emergency Contact - please enter below

No

First Name

Last Name

CARE PROVIDERS AND COVERAGE *

REQUIRED: Case Manager/ Care Coordinator Information:

First Name

Last Name

Phone *

(###)

###

####