WHO IS THIS WATCH FOR? *

Please Complete Watch Recipient / Participant

First Name

Last Name

Wearer Phone *

(###)

###

####

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

No - please enter below

Shipping Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

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

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

Yes - please enter participant Email address below

No

Would a caregiver like access to the participant's data via the online portal? *

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

Yes - please enter participant Email address below

No

Messaging Packages Selection (Select up to 3)

User will receive a once / week message encouraging them in the following areas.

Isolation Messaging

Healthy Eating Messaging

Mental Health Messaging

Laughter is the Best Medicine Messaging

Active Living

None (I prefer not to use any messaging packages)

Medication Reminder Selection

The user will receive a notification reminding them to take their medication at a set time each day selected. What day(s) of the week do you want medication reminder notifications?

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

None (I don't want Med-Minder Notifications)

1st Medication Reminder Time

What time do you want to receive your first Medication Reminder

Hour

Minute

Second

AM PM

2nd Medication Reminder Time

Optional second reminder time

Hour

Minute

Second

AM PM

3rd Medication Reminder Time

Optional third reminder time

Hour

Minute

Second

AM PM

EMERGENCY CONTACT INFORMATION (for PERS) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Optional 2nd Emergency Contact:

First Name

Last Name

Phone

(###)

###

####

Does participant have a Legal Guardian?

Yes - same as Emergency Contact

Yes - different from Emergency Contact - please enter below

No

Case Manager Contact *

REQUIRED: Case Manager/ Care Coordinator Information:

First Name

Last Name

Phone *

(###)

###

####