Wellness Calls: Secure Sign-Up Form

Step 1: Client Information (This is the person we will be calling)

First Name *

Last Name *

Primary Phone *

Secondary Phone

Address *

City *

State *

Postal code *

Are you signing up for yourself or someone else? *

Step 2: Additional Information

Please tell us as much as you like about the person we will be calling. You can also skip this section entirely. Any information you provide will be kept strictly confidential and used only to customize your service and better interact with our client.

Think about what's important to you or your loved one, whether it be for safety, companionship, or other reasons. For example: Medication Remindersat a specific time of day, a simple "How are you feeling today?", etc.

Birthday

Health, Medicine, Activity Reminders

Hobbies, Interests, Notes

Step 3: Primary Contact Person

This is the person we will contact if cannot reach the client or there are any problems. This is typically a family member, close friend, or neighbor, but can be anyone you want.

Contact Person's Full Name

Contact Person's Primary Phone Number

Contact Person's Secondary Phone Number