Private Orders

Programming Information Form

Please ensure any field with an asterisk(*) has been completed.
Important notice:

This form is for private and NDIS orders only.
If your order is being paid for through a funding company, please click here.
What is the client's relationship with Guardian?*

User is new to GuardianHas another Guardian personal alarm & Guardian SIMHas another Guardian SIMHas another Guardian personal alarm
Would the user like to keep their current product active?*

Wants to keep active and use both productsWants to keep active only until the new one arrivesWants to cancel immediately

User & Shipment Details:
User Details:

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

DayMonthYear
CRM: SMS header
Residential Address:

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

We provide a range of shipment methods depending on your preferred delivery address. Here are the available options and costs involved:

PICK UP (WARWICK, WA)

Standard wait time - Free

AUSPOST EXPRESS (AUSTRALIA WIDE)

Standard wait time until order is started - $15

LOCAL COURIER (PERTH METRO POSTCODES 6000 - 6210)

Delivery time varies but is not much slower than AusPost Express - $10
Where do you want this order to be shipped to?*

Same as the residential addressWill pick it up: standard wait time (free)Other:
Street Address:*
Number and street name
Suburb:*
State:*
Postcode*
Delivery Options:*

PERTH Metro Area Only Courier ($10)AusPost Express ($15)
Delivery Option:*

AusPost Express ($15)
Handoff Type:*

Leave in a safe spotSignature on delivery (+$2.95)
Please be aware that by choosing this type of handoff, you take full responsibility for any packages that may be lost or stolen. Guardian Safety Pendants will not be liable for such items.*
Name & Phone Number of Addressee:
This is the person who will be receiving the order in the mail. We may need to contact them in case of complications.
Our office is in Warwick Healthcare Centre at Suite 6 26 Dugdale St Warwick WA 6024, and we are open Monday to Friday from 9 to 5.

Contact Details:
Contact details for the best person to speak to regarding this order.
Do you have a valid email address?*

YesNo
Email Address:*
CRM: fake email
Contact Number:*
Please include area code for landline numbers

Emergency Contact Information:
Sometimes referred to as ECs in this form, these are the numbers that Guardian products will contact in case of an emergency.
This device comes with a dedicated physical SOS button that can speed dial a specific number when pressed. Please fill in the field with your most reliable contact number.
SOS Contact: (Name, Relationship)*
SOS Contact: (Phone Number)*
For landlines, don't forget the area code (e.g. 08)
CRM: SV primary contact
Apart from the number assigned to the physical SOS button, the user can have 3 more speed dial contacts. These 3 contacts will be shown on the home screen at all times and will be just a tap away. If interested, the user can also set a contact picture for the said contacts.
Do you require the device to call emergency services in case none of your ECs answered?*

ECs listed below would sufficeContact 000 as well
CRM: needs ambulance
Contact 1: (Name, Relationship)*
Contact 1: (Phone Number)*
For landlines, don't forget the area code (e.g. 08)
Contact 2: (Name, Relationship)
Contact 2: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 3: (Name, Relationship)
Contact 3: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 4: (Name, Relationship)
Contact 4: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 5: (Name, Relationship)
Contact 5: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 6: (Name, Relationship)
Contact 6: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 7: (Name, Relationship)
Contact 7: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 8: (Name, Relationship)
Contact 8: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 9: (Name, Relationship)
Contact 9: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
Contact 10: (Name, Relationship)
Contact 10: (Phone Number)
For landlines, don't forget the area code (e.g. 08)
When the alarm is activated, the device will call the emergency contacts one by one. It will also:*

Send text to EC1 only (default)Send text to all ECs*
Please note: Selecting option to text all emergency contacts may use a large portion of your credit allotment. It is not recommended if you have more than 3 numbers listed.
Optional: In addition to the above, you can have two more Swissvoice contacts that will ONLY receive a SMS in case of an emergency. If interested, please list two other text receiver contacts in the following field:

Payment Details:
Have you already paid for your Guardian product via our website, over the phone or in office?*

NoYes
CRM: "Already paid"
How the Guardian product will be paid for?*

Qoin (50% Qoin, 50% AUD)Email the invoiceQoin (100%)Card Payment (via Stripe)NDIS (via Portal)Debit from Bank AccountNDIS (Invoiced to plan manager)Cash (Pick ups only)Post the invoiceAlready paid for extras
How the extras will be paid for?*

Qoin (50% Qoin, 50% AUD)Email the invoiceQoin (100%)Card Payment (via Stripe)NDIS (via Portal)Debit from Bank AccountNDIS (Invoiced to plan manager)Cash (Pick ups only)Post the invoiceNone were selectedAlready paid for extras
Please confirm how often you would like to pay for the ongoing professional monitoring costs?*

Yearly ($320 + SIM fees)Monthly ($29 + SIM fees)
How will the ongoing costs be paid for?*

Direct Debit (Card payment via Stripe)Email the invoiceDirect Debit (Bank Account)NDIS (via Portal)Post the invoiceNDIS (Invoiced to plan manager)
How will the ongoing costs be paid for?*

Direct Debit (Card payment via Stripe)Email the invoiceDirect Debit (Bank Account)NDIS (via Portal)NDIS (Invoiced to plan manager)
How will the ongoing costs be paid for?*

Client to payNDIS (Invoiced to plan manager)
You have requested physical invoices in one of the above fields.*

By checking this box...*
Financial Institution Name:
Account Holder's Name:*
BSB:*
Account Number:*
By checking this box...*
NDIS Funding Type:*

Assistive TechnologyConsumables
NDIS Number*
NDIS Plan Dates*
e.g. 25/12/2000 to 24/12/2001
Email address where initial invoice for main Guardian product will be sent to:*
CRM: purchase method
Billing Address:*
This could differ from the residential address.
Email address where invoice for extras will be sent to:*
Email address where ongoing invoices will be sent to:*
Who filled out this form?*
Please enter your full name.
Please enter today's date:*

MonthDayYear

Card Details:
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Almost Done!
Do you have a referral code?
If yes, please enter the code above.
CRM: referral code
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
Do you need help navigating aged care to secure the best mix of services, such as, help at home, moving to retirement, and/or aged care living arrangements? Are you dissatisfied with your current home care services or want help accessing better support, be it at home or in the facility you live in?

Yes, please connect me with an aged care navigatorNo, I am fine
Any additional information that you would like us to know?
Where did you hear about us?*
Thank you for choosing the Guardian MediWatch!
Your order will be dispatched within 1-2 weeks of submitting this form (unless the order is held up due to payment). If the order is not delivered within 4 weeks of submitting this form, contact our office via info@guardiansp.com.au or (08)63369448. Guardian Safety Pendants will not be held liable for lost packages that are not claimed within 6 weeks of the dispatch date.*

Understood.
Should be Empty:

Programming Information Form

Guardian Product Details