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Pendant Activation Form
Please fill out the information below:
Step 1:
Place the pendant on the charger.
Activation
cannot
begin unless it is on the charger.
Is the pendant currently on the charger?
*
Yes
No
Device ID # (UDI: Found on back of pendant or on box)
*
Are you filling this form out for you or someone else?
*
For you
For someone else
Please use the client's legal name here (e.g., Margaret, not Maggie); you can share the name you typically use below!
*
*
*
*
Address
*
*
*
*
Date of Birth
*
Personal Information
Marital Status
*
Single
Married
Divorced
Widowed
Prefer not to say
Gender
*
Male
Female
Please Select those that apply:
Weapons
Speech Impaired
Hearing impaired
Disabled
Oxygen
Med list on fridge
None of these apply
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