Order Form

Section 1 - Client & Emergency Response Address

Client's Name(Required)

Emergency Response Address(Required)

Address City State/Province Zip Code

Phone Number(Required)

Internet Provider(Required)

Yes

Agency Referring(Required)

Device Delivery Address (if the Emergency response address is different)(Required)

Address City State/Province Zip Code

Device Responsible Party(Required)

Responsible Party Phone(Required)

Responsible Party Email(Required)

# of Devices(Required)

Section 2 - Emergency Contact List

Key Holder?(Required)

Yes

Contact Person 1(Required)

Phone Number 1(Required)

Relationship 1(Required)

Key Holder?

Yes

Contact Person 2

Phone Number 2

Relationship 2

Key Holder?

Yes

Contact Person 3

Phone Number 3

Relationship 3

Add more Contacts

Contact Person

Phone Number

Relationship

Special Instructions

Person Requesting Client Order(Required)

Date(Required)

Employee Completing Order Form(Required)

Date(Required)

Phone

This field is for validation purposes and should be left unchanged.

Using Alexa technology, SmartCompanion creates a personalized, whole-home system of smart medical alert devices to help seniors maintain an independent lifestyle and provide caregivers with peace of mind.

For Living Facilities

CONTACT INFO

855-488-1081

info@smartcompanion.care