Sign Up for Your Monitored Medication Dispense

Signup for Your 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 and Phone numbers of the people we will call if we cannot reach.
- 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)

Are there any issues that we need to be aware of should we have to call for a missed dose?

Which Dispenser Are You Choosing?

Next we will gather detail on who you would like us to reach in the event that we cannot reach when we call.

How many people do you want us to try to reach if we cannot contact you?

Name of First Person to Reach:

Relationship to client:

Has Keys?

Yes No

First Number To Try:

Type of Phone:

Second Number To Try

Type of Phone:

Name of Second Person to Reach:

Relationship to client:

Has Keys?

Yes No

First Number To Try:

Type of Phone:

Second Number To Try

Type of Phone:

Name of Third Person to Reach:

Relationship to client:

Has Keys?

Yes No

First Number To Try:

Type of Phone:

Second Number To Try

Type of Phone:

In the event that neither the Subscriber nor their contacts answer our calls, the Subscriber does hereby authorize Towne Monitoring Service to seek to notify and/or obtain assistance. The Subscriber shall be obligated for and agrees to pay any costs and expenses incurred including, but not limited to, ambulance, physician or other medical assistance in obtaining assistance, or any cost whatsoever incurred as a result of the Subscriber's use of the Service.

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?

Are there any special notes or instructions?

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.