Self Monitoring Registration Form

Self Monitoring Registration Form

Please complete this form and return to us to set up the device

Office Use Only
Date

DayMonthYear
Bureau Name
Device #
Device IMEI Number
Device Mobile Number
Safety Device Model
Ringtone Mode
Voice Mode
SOS Voice Prompt
Fall Detect

Customer To Fill In
CareMate Order Number #*
You will find this on your order confirmation email
Purchaser Details
Full Name*

First NameLast Name
Company Name (If Applicable)
Address*

Street Address

Street Address Line 2

CityState

Post Code
Mobile Number*
E-mail Address*
example@example.com
Relationship To Device Wearer*
How Did You Find Out About Us?*
Device Wearer's Details
Full Name*

First NameLast Name
Date Of Birth*

DayMonthYear
Date
Address*

Street Address

Street Address Line 2

CityState

Post Code
Mobile Number *
Email Address
example@example.com
Device Wearer Category*
Does Wearer Have Wifi At Premises?*
Standard Procedure

SOS Button and Fall Detection

If the User is in distress and presses the emergency SOS button on the device, or a fall is detected, the device will play a voice prompt up to 3 times to warn the user prior to sending an alarm.

If the user wishes to cancel this at all they can tap the SOS button to cancel it before the end of the 3rd voice prompt.

After the 3rd voice prompt the preset contacts (Family / Friends / Carer) which we set up will be sent an SMS. The SMS will contain the type of event and the location of the user at the time.

Then any one of the contacts can call the device and it will automatically answer handsfree on speaker mode.

Low Battery Alerts

For extra peace of mind, if the device's battery is at 20% the user will get a voice prompt. At 15% the user will get a voice prompt and an SMS will also be sent to the preset contacts automatically.
Contact List
Contact 1
Full Name*

First NameLast Name
Mobile Number*
Contact 2
Full Name

First NameLast Name
Mobile Number
Contact 3
Full Name

First NameLast Name
Mobile Number
Contact 4
Full Name

First NameLast Name
Mobile Number
Contact 5
Full Name

First NameLast Name
Mobile Number
Contact 6
Full Name

First NameLast Name
Mobile Number
Should be Empty:

Self Monitoring Registration Form

Purchaser Details

Device Wearer's Details

Contact List

Contact 1

Contact 2

Contact 3

Contact 4

Contact 5

Contact 6