Personal Info
*This can be filled out in stages however everything under the Personal Info section will need to be completed initially so that we can create the requisite accounts.
What is your name?
What is the senior's name?
What is the senior's phone number?
What is the senior's address? (Please include ZIP/Postal Code)
What is the senior's height?
What is the senior's weight?
What is the senior's birthday?
When is the scheduled install date?
Wearable Information
Which wearable will be used? (Please delete all that do not apply)
Garmin, Fitbit, Fitpolo
Which devices will need to be provided? (Please delete all that do not apply)
- Omron BP BT cuff (arm)
- Omron BP BT cuff (wrist)
- Garmin scale (wifi)
- iHealth Oximeter BT (finger)
- Sleep Image logger (baseline only)
- Glucose meter (TBD-Future)
- AliveCor EKG monitor (TBD-Future)
Care Giver Account Information
WellAssist Web Accounts Needed (CareGivers)
Enter the name and email address for CareGivers/Family members who will be accessing the WellAssist Web app to setup routines on behalf of the senior above.
Enter CareCircle Member Information (LIMIT 4)
Please enter the First name, Last name and Phone number for each of the CareGivers to be used for CareCircle calling.
Enter Live Connect Member Information (LIMIT 8)
Please enter the First name, Last name, Phone number for each of the members to be used for Live Connect calling.
Upload Live Connect Photos (LIMIT 8)
Have all ready to upload. Please set filename = CareGiver name. (.png, .jpg file format only). Images are to be used in the Live Connect outbound Phone calling.