Medica

WHO IS THIS WATCH FOR? (Member Information) *

Please Complete Watch Recipient / Participant

First Name

Last Name

Member 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

EMERGENCY CONTACT INFORMATION (for PERS) *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Select to add optional 2nd Emergency Contact

Setup Medication Reminders?

Yes

No

Setup One-Touch Call my Caregiver? *

Yes

No

Select Personalized Messaging Packages (Up to 3)

Daily Stretch

Daily Inspiration

Daily Riddle

Daily Devotion (Christian)

Weekly Reducing Isolation

Weekly Healthy Eating

Weekly Active Living

Weekly Mental Health Check-in

Weekly Laughter is the Best Medicine

CARE COORDINATOR *

REQUIRED: Care Coordinator Information

First Name

Last Name

Phone *

(###)

###

####