SafeSeniorsm Program

assisted independence
Medication Reminders & Well Being Calls
30 Day Free Trial

If you are pleased with the service then you can choose to continue for the low monthly fee of only $19.95 per month after the free trial period. No contract required. Cancel anytime.
Please fill in the information below to get started . . .


*Senior’s Name (required):
*Senior’s Phone #
*Senior’s Emergency Contact Name (required)
*Senior’s Emergency Contact Phone # (required)
*Senior’s Emergency Contact E-mail (if applicable)

*Type of Service Requested (required)
Well-Being:
Medication:

*Days for Calls
All Days Mon: Tues Wed: Thurs Fri: Sat Sun:

WELL BEING CALL CHOICES:
Time 1: am    OR     pm
Time 2: am    OR     pm
Time 3: am    OR     pm

Random Time (time window 2 - 6 hrs – for well being calls only):

MEDICATION REMINDER CALLS:
Time of 1st Med Call and Name of Medications (up to 6 meds may be listed)

     am       pm

1)       2)
3)       4)
5)       6)


Time of 2nd Med Call and Name of Medications (up to 6 meds may be listed)

     am       pm

1)       2)
3)       4)
5)       6)


Time of 3rd Med Call and Name of Medications (up to 6 meds may be listed)

     am       pm

1)       2)
3)       4)
5)       6)



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