WHO IS COMPLETING THIS ORDER FORM? *

Watch Recipient/ Participant

Case Manager/ Care Coordinator

WHO IS THIS WATCH FOR? *

Please Complete Watch Recipient / Participant

First Name

Last Name

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 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 *

(###)

###

####