Check-In Calls Signup

Please take a few minutes and fill out this form so that we can get started creating your Automated Care Calls 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 our system will be calling, 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 calls and any relevant notes regarding the calls.
- Desired wait time between calls to be made.

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.

Which type of Automated account would you like to set up?

First, we will collect information regarding the person that our system will be calling.

Name of person to be called:

Complete Address of person to be called (please include Street, City, State, Zip):

Date of Birth:

Primary Phone Number

Are there any issues that we should be aware of when making the call?

What is the reason for the call?

The time delay between calls applies to all the calls made. So - if we were to try you house and cell, with your house and cell twice, and your call was scheduled for 9a with a 10 minute delay, your call cascade would look like: 1st call to house at 9;00, 2nd call to house at 9:10, call to cell at 9:20, 2nd call to cell at 9:30, etc, etc. Please keep this in mind as you choose your call interval.

How much time delay (in 10 minute increments) do you want to have between call attempts?

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

Home many times should we try the primary phone?

Should we try calling the clients secondary phone first if we cannot reach on the home phone?

Important Note: We will attempt each contact number one time in the event that we are unable to connect with the client as outlined above. In the unlikely event that we cannot reach anyone at all, the Care Call will be transferred to our operators and a final attempt to reach on the primary number will be made. If still unsuccessful, we will request a well check from local authorities.

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 when you would like us to call and any other information you think we would need.

How many calls would you like us to make each day?

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

If no call is desired - please indicate that by simply writing No Call in the box.

Monday

Call Time

Tuesday

Call Tue

Wednesday

Call Wed

Thursday

Call Thu

Friday

Call Fri

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 Care Calls 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.