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Subscriber

Your Name

*First Name

*Last Name

*Date of Birth

Gender

*Subscriber's street address (line 1)

Subscriber's street address (line 2)

*Subscriber's city

*Province

*Subscriber's postal code

Use as mailing address

Mailing address (line 1)

Mailing address (line 2)

City

Province

Postal code

*Subscriber's home phone number

*Do you have more than one phone in your home?

Subscriber's cell phone number

Location of hidden key or lock-box code for Emergency Services (optional)

Second Subscriber

There is a second person in the home who requires a pendant (extra fees apply)

First Name

Last Name

Date of birth

Doctor's name

Allergies

Life saving medications

Responders information:

For when an ambulance is not needed but assistance is (we recommend that responders be no further than 10 to 12 minutes from subscriber). We also recommend at least 1 responder. If no responder is given, Emergency Services (911) will be the first responder. Responders will be called in the order they are listed.

Responders

First responder

First Name

Last Name

Street address (line 1)

Street address (line 2)

City

Postal code

Home phone number

Cell phone number

Minutes away from subscriber

Has a key
Yes

Relationship to subscriber

Second responder

First Name

Last Name

Home phone number

Cell phone number

Minutes away from subscriber

Has a key

Relationship to subscriber

Third responder

First Name

Last Name

Home phone number

Cell phone number

Minutes away from subscriber

Has a key

Relationship to subscriber

Next of kin

*First name

*Last name

*Relationship to subscriber

*Mailing address (line 1)

Mailing address (line 2)

City

Postal Code

*Home phone number

Cell phone number

Work phone number

Email address

Has Power of Attorney

Medical

Doctor's name

Allergies

Life saving medications

Equipment

Please select each item individually to learn more information about our equipment.

* Please note that if you do not have a landline with Bell or Eastlink, you will require a cellular device.

Basic AlarmRead More

Basic Alarm + Cellular

Automatic Fall DetectionRead More

Automatic Fall Detection + Cellular

Stove SensorRead More

Medication DispenserRead More

On-The-MoveRead More

Method of payment

Automatic withdrawal from bank account monthly (pre-authorized payments)

Post-dated cheques

Billed/Invoiced Monthly

Name of the person to bill

Phone number

Billing address

Funded

Name of Care Coordinator (If approved for the personal Alert Assistance program)

Phone Number of Care Coordinator

Is there anything else you would like to share with us?

*How did you hear about Northwood Intouch

Email address for confirmation

Due to COVID-19, we are currently offering self installation only. Equipment will be couriered to you at no cost. Equipment comes with easy to follow instructions and telephone support should you need additional assistance. If you have concerns, please contact our office at (902) 492-3346 or 1-800-461-3346.
yes, self-installation

Name & Address of person to send equipment to if not the client

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