Reemo Wellness Watch Order Form Product information:Reemo Wellness Watch Package Need Help? orders@reemohealth.com 1-866-973-5133 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 Would the participant like to access the online user portal? * User 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? * User portal displays activity history (steps, heart rate), gps location, and watch status. Yes - please enter caregiver 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 * (###) ### #### Email * Message How did you hear about us? Thank you!
