Application form

* Indicates required

Subscriber











Use as mailing address








Note: An 8-Pin Jack or line seizure jack is a unique telephone jack that allows your Intouch equipment to place a help call if a telephone extension is in use or left off the hook. It is typically recommended in cases where a subscriber has multiple phones or has a dial-up Internet connection. 8-pin jacks are provided by most telephone providers. If you are interested in having one installed, simply contact your telephone provider and request an installation appointment. A special cord is required to connect your Intouch equipment to the 8-pin jack. This cord is provided by Intouch prior to or after the 8-pin jack has been installed.





Second Subscriber

There is a second person in the home who requires a pendant (extra fees apply)







Responders information:

For when an ambulance is not needed but assistance is (we recommend that responders be no further than 10 to 12 minutes from subscriber). We also recommend at least 1 responder. If no responder is given, Emergency Services (911) will be the first responder. Responders will be called in the order they are listed.

Responders

First responder










Has a key


Second responder






Has a key


Third responder






Has a key


Next of kin










Has Power of Attorney

Medical




Equipment

Please select each item individually to learn more information about our equipment.

Basic Unit and Standard Pendant - $43/month

Additional Basic Pendant - $5/month

Basic Unit with Fall Detector - $55/month

Bed Sensor - call for pricing

Stove sensor - call for pricing

Motion Detector - call for pricing

Flood Detector - call for pricing

Extreme Temperature Sensor - call for pricing

Medication Dispenser - call for pricing

Incontinence Sensor - call for pricing

Pressure Mat - call for pricing

GPS - call for pricing

Method of Payment

Automatic withdrawal from bank account monthly (pre-authorized payments)

Billed/Invoiced Monthly








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