mCareWatch Orders

mCareWatch Form
CRM: Product
By checking this box, you understand that Guardian is simply an affiliate provider for mCare, and all ongoing support, troubleshooting, refunds, and change of mind are at the discretion of mCare.*

User & Shipment Details:
User's Details:

Please fill in the details relevant to the person who will be using the mCare product.
First Name:*
Last Name:*
Date of Birth:*

DayMonthYear
Phone Number:*
Email Address:*
Does the user have any medical conditions?
Residential Address:

Where the product's user usually resides.
Street Address:*
Number and street name
Suburb:*
State:*
Postcode:*
Delivery Address:*

Buyer's Details:
What's your relationship with the user?*

I am the user.Buying this for another person.Representative of a funding organisation.
First Name:*
Last Name:*
Relationship to the user:*
Funding Organisation:*
Street Address:*
Number and street name
Suburb:*
State:*
Postcode:*
Phone Number:*

Premium Plans:
Programming Details

Following contacts are the numbers that the device will contact in case of an emergency.
Contact 1: (Full Name)*
Relationship to the user:*
Mobile Number:*
Alternative Phone Number:
Email:*
Address:*

Street Address

Street Address Line 2

SuburbState

Postcode
Contact 2: (Full Name)
Relationship to the user:
Mobile Number:
Alternative Phone Number:
Email:
Address

Street Address

Street Address Line 2

SuburbState

Postcode
Monitoring Protocol
When should the monitoring company call 000?*

Whenever the SOS is pressedWhen the user requests an ambulance OR when an authorised contact agrees to the summoning of an ambulanceWhen the user OR the authorised contact is uncontactable
CRM: ProfMon protocol
mCareWatch Premium plans require a key safe installed outside of your premises.

The Monitoring Company will provide your key safe details to emergency staff in order for them to access your premises in case of an emergency.

If you don't have a key safe, we will provide you one for $49.
Do you have a key safe installed outside of your property?*

Already have a key safePlease provide a key safe (+$49)
What the Key Safe PIN will be?*
If the user already has a key safe, please enter the code here.
Where will the Key Safe be located?*
If user already has a key safe located outside their property, please indicate it here.
Name of person agreeing on behalf of the user:*

Payment Details:
How the initial invoice will be paid for?*

Already paid onlineCard payment via StripeNDIS (via Portal)Email the InvoiceNDIS (Invoiced to plan manager)Funding company
How will the ongoing costs be paid for?*

Direct Debit (Card payment via Stripe)Covered by funding companyNDIS (Invoiced to plan manager)Email the InvoiceNDIS (via Portal)

Please choose the items you want to pay for:

mCareWatch + Basic Plan

$558.00AUD Billing period:

mCareWatch + Standard Plan

$574.00AUD Billing period:

mCareWatch + Premium Plan

$594.00AUD Billing period:

Premium Plan's Key SafeIf you have chosen premium plan and you do not already have a key safe, you are REQUIRED to select this item.

$49.00AUD Quantity

Total

$0.00AUD

Almost Done!
Any additional information that you would like us to know?
For example, you would like to buy the mCareWatch for a trial.
Are you dissatisfied with how your NDIS funds are not meeting your requirements, how your plan is managed, or how your funds are allocated? Would you like help getting onto the NDIS?

Yes, help link me with an NDIS serviceNo, I'm fine
Who's filling out this form?*
Please enter your full name
Should be Empty:

mCareWatch Form