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.