To order your Personal Assist GPS Tracker unit, fill in the PDF, and post it to us, OR:
Click Pay Pal Button to purchase
Personal Assist GPS unit
After filling in the form, please pay via:
- Pay by credit card – use our By Now Paypal button
- Post a cheque made out to Healthwatch Co Ltd – *The cheque needs to be cleared before unit can be dispatched.
- Direct Credit or Internet Banking pay to: Healthwatch Co. Ltd,
Account number: 030239 – 0114421-00
INSTRUCTIONS FOR FILLING IN THE APPLICATION FORM:
- Fill in the user of the units full contact details.
- If you are the Admin person, or carer, then fill your contact details where it says administrative contact, in case we need further information.
- Please provide main S O S person contact details; they will be the first person that will receive the ALERT
- Optional: a second person contact details as a back up ALERT if the first person does not respond.
- There is option for one more person to be a 2nd back up contact to receive an ALERT
- Sign application, then enter referral agent name, (if you were referred by an agent).
POST US THE FILLED IN FORM
- PRINT out the Application Form,
- Fill it in and post, (just the first page)
- Attach your cheque with the application (if applicable) to:
PO Box 316086
If you download this form in a Word format and click ENABLE EDITING, and save it to your computer, you can fill it in electronically, re-save it, then attach it to an email to:
All Forms to go to: Pat Young (firstname.lastname@example.org)
Customer Enquiries: 09 479-1069
Remember to add/insert your name, in the REFERRING AGENT NAME field, in the Word Doc form, SAVE IT, before distributing the Application Form to your customers.