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Client Details
Client Details
Title
*
First Name
*
Last Name
*
*
Address 1
*
*
Address 2
*
City
*
*
State
*
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
*
*
Contact Phone Number
*
*
Email Address
*
*
Date Of Birth
*
*
Health Information
Is a keylock available?
*
Is a keylock available?
No
Is a keylock available?
Yes
Health Detail
Fully Vaccinated for COVID
*
Fully Vaccinated for COVID
No
Fully Vaccinated for COVID
Yes
Does the client have problems with: (Tick all that apply)
Falls
Hearing
Memory
Diabetes T1
Mobility
Speech
Allergies
Diabetes T2
Heart Disease
Vision
Asthma / Airways
List any other medical conditions including allergies
*
Emergency Contacts
The emergency contact should live within 30 minutes of the client - If only one contact is listed please select a key Lock
First Name
*
*
Last Name
*
*
Phone Number
*
*
Address 1
*
*
Address 2
*
City
*
*
State
*
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
*
*
Relationship To Client
*
*
Does this contact have a spare key?
Does this contact have a spare key?
No
Does this contact have a spare key?
Yes
The emergency contact should live within 30 minutes of the client
First Name
*
Last Name
*
Phone Number
*
Address 1
*
Address 2
*
City
*
State
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Postcode
*
Relationship to Client
*
Does this contact have a spare key?
Does this contact have a spare key?
No
Does this contact have a spare key?
Yes
Service and Payment Details
Type of Service Required
*
Home Only
Home and Mobile
Solo Watch
Home and Solo Watch
MePACS Solo Watch
40mm Cream Gold Watch
40mm Graphite Watch
44mm Graphite Watch
The client has good Telstra Mobile Phone coverage in their home
I can confirm
The watch needs to be charged regularly and I/the client is able to operate touch screen technology
I understand
Additional Services
Mobile Alarm $385
Additional Pendant $70
Key Lock $80
Daily Call $6 a month
Monthly Response Fee $
*
Choice of Installation
*
MePACS to Install $140
Self-Installation and Postage (One Service) $29
Self-Installation and Postage (Two Services) $39
Installation Charge $
*
One off Equipment Charge $
*
Total Upfront Charges $
*
Billing Information
Billing Party
*
Client
Other Party
Billing Name
*
*
Billing Address 1
*
*
Billing Suburb
*
*
Billing State
*
VIC
ACT
NSW
NT
QLD
SA
TAS
WA
Billing Postcode
*
*
Billing Email Address
*
*
*
Billing Phone
*
*
Additional Information
*
Who should we contact regarding Installation?
*
Client
Other
I agree to pay for the above MePACS Services and agree to the Terms and Conditions
*
Admin
Form Type
*
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HCP
NDIS Form
MePACS Web
MedAdvisor
Opportunity ID
*
*
OPPID
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PayWay Query String
*
Name
*
Previous Watch Choice
*
