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County Client Form
Step 1: Place the pendant on the charger
Which county are they with?
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Device ID # (UDI: Found on back of pendant or on box)
Please use the client's legal name here (e.g., Margaret, not Maggie); you can share the name you typically use below!
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Address
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Date of Birth
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Personal Information
Marital Status
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Marital Status
Single
Married
Divorced
Prefer not to say
Gender
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Gender
Male
Female
Please Select those that apply:
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Please Select those that apply:
Weapons
Speech Impaired
Has pets
Pets bite
Hearing impaired
Disabled
Child in house
Oxygen
Med list on fridge
Add fall detection ($4.99/month - First month free)
None of these apply
Call List Information
Name, Phone #, Relationship
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Notes*
*Remind client to have medication list on the fridge*
*Payment will be billed to the county*
Submit
