IMD MD.2 User Manual page 51

USER & CAREGIVER WORKSHEET
Please use this form to provide user and caregiver contact information prior to calling the Support Center. When this is
completed, either Fax (1-603- 472-4807), call in (1-877-472-9037) or mail this information.
MD.2 Serial Number:
USER INFORMATION
User Name:
User Street Address:
User City:
User Home Phone Number:
FAX Number:
CAREGIVER INFORMATION
If a dosage is missed by the user, the MD.2 will call caregivers in the following order.
Caregiver # 1
Address
Phone Number (exactly as dialed from patient's phone):
FAX Number:
Caregiver # 2
Address
Phone Number (exactly as dialed from patient's phone):
FAX Number:
Caregiver # 3
Address
Phone Number (exactly as dialed from patient's phone):
FAX Number:
Caregiver # 4
Address
Phone Number (exactly as dialed from patient's phone):
FAX Number:
When would you like to schedule the set up of the MD.2? ___________________________
(You should plan to schedule the set up at a time when you will be at the user's home and ready to install and load the machine with medications.)
Interacative Medical Developments
(The serial number is located on the label inside the locked door.)
State:
User Time Zone: ATL EST CST MST PST AST HI
Email:
Relationship to User:
City:
Email:
Relationship to User:
City:
Email:
Relationship to User:
City:
Email:
Relationship to User:
City:
Email:
Date of Birth:
Gender: F M
Zip:
State: Zip:
State: Zip:
State: Zip:
State: Zip:
49