EMS Customer Monitoring Information Form

Professional Monitoring of a Medical Alarm System
Customer Information Sheet

If you require assistance completing this form, please email: care@emsas.com.au or call 1300 699 159.

Device Type

safeTwear PendantMy LifeWatch

Name of person using the alarm*

First NameLast Name

Preferred Name (if different from above)

Spouse Full Name

Date of Birth*

DD-MM-YYY

Gate Code for Ambulance (if applicable)

Address (start typing until your address appears and then click on your address from the drop down list)

Village Name (if applicable)

Phone Number (mobile or landline)*

Area Code for mobile type 61Phone Number

Alternate Number (if applicable)

Area Code for mobile type 61Phone Number

E-mail

example@example.com

Keysafe Location*

If you don't have one, type 'NA'.

Keysafe Code

Emergency Contact 1 (Required)*

Phone Number (mobile or landline)*

Area Code for mobile type 61Phone Number

Relationship to Emergency Contact 1

Do they live close to you?*

Yes - Live Close & Have KeysYes - Live Close & NO keysNo

Emergency Contact 2 (Required)*

Phone Number (mobile or landline)*

Area Code for mobile type 61Phone Number

Relationship to Emergency Contact 2

Do they live close to you?*

Yes - Live Close & Have KeysYes - Live Close & NO keysNo

Emergency Contact 3

Phone Number (mobile or landline)

Area Code for mobile type 61Phone Number

Relationship to Emergency Contact 3

Do they live close to you?

Yes - Live Close & Have KeysYes - Live Close & NO keysNo

Emergency Contact 4

Phone Number (mobile or landline)

Area Code for mobile type 61Phone Number

Relationship to Emergency Contact 4

Do they live close to you?

Yes - Live Close & Have KeysYes - Live Close & NO keysNo

Relevant information on any ALLERGIES - 1. List what the allergy is. 2. What the reaction is (i.e. affect breathing, causes itching) AND 3. What steps to take (i.e. medications such as EpiPen).

Brief Health History that might be relevant in an emergency (i.e. Diabetes, High Blood Pressure and/or blood thinning medication, Any Heart Conditions, Parkinson's, Asthma etc).

What is your approximate weight in kilograms? (This is often asked by the ambulance in the event of a fall).*

General Notes and Other Relevant Information - Include any pets (and their names and demeanour) that emergency service responders might encounter (i.e. Dalmatian named Spot, usually friendly).

Please complete if you have any additional information to share (i.e. any added information about accessing the property in an emergency).

Date*

Date

Terms and Conditions of Offer:

Where the possession of goods is to be transferred to the customer it is expressly understood that these goods remain the property of Emergency Medical Services until paid in full.
Despite the domicile or residence of any of the parties to this Contract, the parties covenant that this Contract shall be governed by and construed in all respects in accordance with the law of the State of Queensland and submit to the non-exclusive jurisdiction of the Court of the State of Queensland with respect to any legal proceedings relating to this Contract.
The System has a 12 month warranty, the warranty covers any fault or failure of the system, it does not cover accidental or water damage.
The monitoring applies only to the person/s listed on this form and is not transferable.
Emergency Medical Services systems use the Telstra mobile network, the customer understands and agrees that Emergency Medical Services cannot be held responsible for any network outages that may affect a failed alarm or in the instance that Telstra makes future changes to their network that renders the system incompatible, this is not covered by the warranty. Please note: Telstra is the first choice, other carriers may be used in circumstances where their network coverage is deemed more suitable and the same conditions apply to all mobile carriers.
I acknowledge, Emergency Medical Services is not a government organisation and acts as a private enterprise. I permit Emergency Medical Services to act as instructed via contact with Emergency Medical Services and/or family using best practises on receipt of a distress/panic alert from my/our household.
I acknowledge that Emergency Medical Services Pty Ltd, its employees, parent companies, subsidiaries or affiliates are exempt and not liable for any ambulance and/or hospital costs incurred.

It is our understanding that Health Care Concession Card, Pensioner Concession Card, and Commonwealth Seniors Health Card holders are entitled to free ambulance transport services. If you are not eligible for a concession and want to be covered, you can purchase insurance from a private health fund.

I acknowledge that Emergency Medical Services Pty Ltd, it's employees, parent companies, subsidiaries or affiliates are exempt and not liable for any ambulance and/or hospital costs incurred.

Signature*

Comprehensive Details:
The safeTwear medical alert device and My LifeWatch come with a standard 12 month warranty from date of purchase. If the device has a manufacturing defect causing it to fail within the first 12 months of purchase, we will replace it free of charge including shipping.

Troubleshooting procedure: If your safeTwear or My LifeWatch device has stopped working please contact the safeTcare Team on 1300 699 159 to speak with a Technical officer who will help you determine the cause of the problem and fix it if possible.

How to claim against your warranty: If after consulting with the safeTcare team the device is still not working, the technical officer will either authorise for a new device to be mailed immediately or you may be asked to return the device for a warranty claim assessment, depending on the nature of the fault.

Please be aware your warranty can become void if any of the following have occurred:

(a)              The device case has been opened or been tampered with.
(b)              The device has been modified or not used in accordance with the instructions supplied.
(c)               The device has been dropped or suffered damage from physical impact.
(d)              The device has been damaged by a fire or has been damaged by being exposed to excessive heat
from direct sunlight or other sources.
(e)              The device has been used with an incorrect power adaptor.
(f)               The device has been subject to an incorrect voltage due to lightning or a power surge.
(g)              The device has been subject to a heat or contaminated liquid, causing a failure.
(h)              The device has been submerged in water (i.e. pool, washing machine, bath etc).

Your guarantee under Australian consumer law.
Our goods and services come with guarantees that cannot be excluded under the Australian Consumer Law.
For major failures with the service, you are entitled:
- to cancel your service contract with us; and
- to a refund for the unused portion, or to compensation for its reduced value.
You are also entitled to choose a refund or replacement for major failures with goods. If a failure with the goods or a service does not amount to a major failure, you are entitled to have the failure rectified in a reasonable time. If this is not done you are entitled to a refund for the goods and to cancel the contract for the service and obtain a refund of any unused portion. You are also entitled to be compensated for any other reasonably foreseeable loss or damage from a failure in the goods or service.

Fair Use Policy:
Emergency Medical Services Pty Ltd has adopted this Fair Use Policy to prevent unreasonable or excessive usage of our Services. This Fair Use Policy applies in relation to the use of the safeTwear or My LifeWatch medical alert systems and pendant, provided by Emergency Medical Services Pty Ltd. Emergency Medical Services Pty Ltd may update the terms of this Fair Use Policy from time to time.

Prohibited use
The SIM must only be used in the safeTwear or My LifeWatch medical alert system and pendant. The SIM must only be used for emergencies and not for general calls. You must not use or allow any person to use a Service in a way that Emergency Medical Services Pty Ltd reasonably considers to be:

·        a breach of any law, code or regulatory standard;
·        a breach of the Terms and Conditions (see above and over)
·        Likely to disrupt the provision of Services to other customers
·        Otherwise unreasonable or excessive

Breach of Fair Use Policy
Where Emergency Medical Services Pty Ltd, in its sole discretion, considers that you have breached this Fair Use Policy, Emergency Medical Services Pty Ltd will notify you of the breach and ask you to stop any prohibited activity. If, after being contacted as above, you continue to be in breach of this Fair Use Policy, Emergency Medical Services Pty Ltd may without further notice:

· Limit, suspend or terminate a Service in accordance with our rights under the Terms and Conditions;
and/or
· Report your conduct to any relevant law enforcement or regulatory authority.

The SIM card remains the property of Emergency Medical Services Pty Ltd.

Contact details for Technical Support

care@emsas.com.au 1300 699 159 www.emsas.com.au

Emergency Contacts