Title

Name

Preferred Language Preferred Language French English

Date of Birth (DD/MM/YYYY)

Address:

Apt #:

Ring #:

City:

Province:

Postal Code:

Intersection:

Tel #:

Other #:

Landline telephone provider:

Email:

Home alarm system? Home alarm system? Yes No

Do you have a lockbox? Do you have a lockbox? Yes No

Lockbox code:

Do you live alone? Do you live alone? Yes No

Do you require a Subsidy? Do you require a Subsidy? Yes No

Notice of Assessment required Notice of Assessment required Copy provided

Do you identify as an Indigineous Person? Do you identify as an Indigineous Person? Yes No No Selection

Name

Tel #:

Relation:

Notes:

Allergies:

Location of medication:

Medical information for responders

Special requirements

Referral information: Referral information: Bruyère Client Other hospital Advertisements Support worker Medical office Family & friends Social media ODSP / POSPH Veterans affairs Other

Other

1. Name:

1. Relation:

1. Home #:

1. Cell #:

1. Work #:

1. Email:

1. Alert preference 1. Alert preference Email Text / SMS Portal access

2. Name / Nom:

2. Relation:

2. Home #:

2. Cell #:

2. Work #:

2. Email:

2. Alert preference 2. Alert preference Email Text / SMS Portal access

3. Name:

3. Relation:

3. Cell #:

3. Home #:

3. Work #:

3. Email:

3. Alert preference 3. Alert preference Email Text / SMS Portal access

Building superintendent #:

Building emergency service #:

I wish to receive periodic information from Red Dot Alerts I wish to receive periodic information from Red Dot Alerts Yes No

Terms of Service Terms of Service I agree to the Terms of Service and to provide a completed pre-authorized payment from prior to the start of the service. / J’accepte les conditions de service et de fournir le formulaire de paiement préautorisé complété avant le début du service.

Client or guarantor name:

Signature

Date