Referral form - VitalCall

1 Referral form It's easy to refer VitalCall Email Fax 1300 554 483. Online DVA Gold Card holder YES NO. AFFIX PATIENT'S LABEL. (IF AVAILABLE) Patients with a DVA gold card require a D9199 to be completed during an in-home assessment with an Occupational Therapist and forwarded to VitalCall .*. * Healthcare professionals only Mr/Mrs/Ms/Miss Additional comments Select Date of request Preferred time frame for install Referrer's name Select Patient's name Organisation (if applicable). Date of birth Department (if applicable). Phone number (inc area code) Address Mobile number Suburb Address State Postcode Suburb Email address REFERRER'S DETAILS. State Postcode I am happy to receive information electronically from VitalCall relating to new products, promotions, industry developments and others.

2 Email address Phone number (inc area code). I am happy to receive information electronically from VitalCall relating MY PATIENT'S DETAILS. to new products, promotions, industry developments and others. Discounted Install $ * (Normally $ ). Who should VitalCall contact to make arrangements Discounted Monthly Monitoring $ *. for the installation? Please list name and relationship (Normally $ ). Select Your patient will be offered a no-obligation, free in-home demonstration of the VitalCall service. Your patient is entitled to receive the VitalCall Personal Emergency Response Friend/family phone number (inc area code). Service at the discounted Referral price below if they choose to have the system installed following this demonstration. Client's consent YES.

3 Pricing is available for the installation of a standard VitalCall pendant *Please note special pricing is available to new VitalCall clients and unit only. The installation fee and first month's monitoring fee only. #Pricing denotes GST, normal Retail installation is $ are payable on the day of installation. Other payment options such and Monitoring $ per month. All prices in this document are is as monthly direct debit may be arranged with the VitalCall agent on effective from 01/07/2014 to 30/06/2015 and is subject to change the day, after a minimum of $ is paid. Referral must be made without notice. by a healthcare professional to access this special pricing. VitalCall is a division of Chubb Fire & Security Ltd. ACN 000 067 541. 1300 360 808 |