SERVICE REQUEST

A Watchful Eye (“AWE”) provides observation and feedback to families and friends on the apparent care being provided to their loved ones at nursing homes and similar facilities. AWE is not a healthcare provider and does not offer or provide an assessment or evaluation of the adequacy, quality of care, we simply report what we see or are told by the resident.

AWE will dispatch one of its informed representatives to the facility for a 15–30 minute visit to make and record observations of the conditions then observed. AWE will endeavor to submit an electronic or fax report of each visit within 24-hours after conclusion. The report, when possible and appropriate, will include telephone camera photographs. The customer is responsible for ensuring that AWE has access to the facility and the loved one at the time of the scheduled visit.

Unless paid in advance pursuant to one of the packages describe below, payment for each visit is due without invoice electronically or by wire transfer within 24 hours after the issuance of each report. The amount due for each visit is based upon the number of visits reserved by the customer. Those amounts will be stated on the service statement executed by client prior to commencement of service.

**($.20 per mile will be assessed if the facility is located more than 25 miles from AWE’s post office box)

By signing this form, I understand that all visits are to be scheduled and completed within 90 days from the date of acceptance of service agreement. Customer is responsible for full payment for all reserved visits unless AWE fails to complete visit and submit report, unless prevented by causes beyond its control, such as being denied access to the facility on the scheduled visitation date.