Sign Up for Your Monitored Medication Dispense

Signup for Your Self Monitored Medication Dispenser

Please take a few minutes and fill out this form so that we can get started on your Medication Dispenser account! Please provide as much information as possible. We will review your document after its submitted and contact you if we have any questions.

Please note: Aside from the information regarding the person the machine will be used for, you will need the following information to complete this form:
- Names, Phone number(s) and email address of the people the system will contact should a dose be missed.
- Times for the dose(s) and any relevant notes regarding the person taking the medication.

Once you complete this form, your completed information will be sent to us and a copy will be sent to you as well. Should you have any questions, please feel free to contact us and we will be glad to help you through this process.

First, we will collect information regarding the person that we will be using the MedReady.

Name of user:

Complete Address of user (Street, City, State, Zip):

Date of Birth:

Home Phone Number

Cell Phone (If Needed)

Which Dispenser Are You Choosing?

Next we will gather detail on who you would like the system to reach in the event that a dose is missed.

How many people do you want to be reached in the event of a missed dose?

Name of First Person to Notify:

Relationship to client:

Has Keys?

Yes No

Phone Number 1:

Type of Message:

Phone Number 2 (If desired):

Type of Message:

Email Address (if email notification is desired):

Name of Second Person to Reach:

Relationship to client:

Has Keys?

Yes No

Phone Number 1:

Type of Message:

Phone Number 2 (If desired):

Type of Message:

Email Address (if email notification is desired):

Name of Third Person to Reach:

Relationship to client:

Has Keys?

Yes No

Phone Number 1:

Type of Message:

Phone Number 2 (if desired):

Type of Message:

Email Address: (if email notification is desired):

OK - now we'll gather information about what time the dose(s) should be and any other information you think we would need.

How many doses do you need each day?

When filling in the time, please write times as 1115A or 700P as this will help avoid any confusion. Thank you!

1st Dose Time

Please choose how long the system should wait to notify that a dose has been missed?

Please enter the name and email address of the person completing this form:

Your Name:

Your Email Address

That's it , you've finished!

Below you will see our Medication Monitoring agreement. This form, along with the answers that you've given above, will be sent to the email address that you provided above as record of completion. Upon review from our programmers, we will contact you with any questions we may have and to arrange payment.

Thank you for choosing Towne - We look forward to serving you.