Agent Info to Order Personal Assist


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Click here to download
our Application Form in PDF so you can post it to us

To order your Personal Assist GPS Tracker unit, fill in the PDF, and post it to us, OR:

download-button-as-Word

 

 

Click here to download Form as Word format so you can email it to us.


Click Pay Pal Button to purchase
Personal Assist GPS unit




After filling in the form, please pay via:

PAYMENT OPTIONS

  • 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,
    WestPac Bank,
    Account number: 030239 – 0114421-00

INSTRUCTIONS FOR FILLING IN THE APPLICATION FORM:

  1. Fill in the user of the units full contact details.
  2. If you are the Admin person, or carer, then fill your contact details where it says administrative contact, in case we need further information.
  3. Please provide main S O S person contact details; they will be the first person that will receive the ALERT
  4. Optional: a second person contact details as a back up ALERT if the first person does not respond.
  5. There is option for one more person to be a 2nd back up contact to receive an ALERT
  6. Sign application, then enter referral agent name, (if you were referred by an agent).

POST US THE FILLED IN FORM

  1. PRINT out the  Application Form,
  2. Fill it in and post, (just the first page)
  3. Attach your cheque with the application (if applicable) to:

Pat Young,
HealthWatch-Medical,
PO Box 316086
Wairau Valley
Auckland 0760

EMAIL OPTION

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 (pat@healthwatch-medical.co.nz)

Customer Enquiries: 09 479-1069

AGENTS:

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.