WHO IS THIS WATCH FOR? *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Phone *

(###)

###

####

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 WATCH OPTIONS

No - please enter below

ONLINE PORTAL ACCESS *

Indicate if member would like access to the user portal: displays activity history (steps, heart rate) and watch status.

Yes

No

EMERGENCY CONTACT INFORMATION *

When an emergency call is made, the call center operator will have the emergency contact(s) information available to call if needed.

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Optional 2nd Emergency Contact:

First Name

Last Name

Phone

(###)

###

####

Case Manager Information *

First Name

Last Name

Phone *

(###)

###

####

I am attaching authorization to this order form: *

Yes - uploaded below

No - will e-mail to orders@reemohealth.com