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FAIRVIEW LIFELINE APPLICATION

Welcome to Fairview Health Services secured LIFELINE APPLICATION form. If you have questions about this form, please contact us at 952-885-6185. To complete this form online, please have the following information available:

  • Applicant's information such as address, phone number and date of birth
  • Applicant's health conditions, including any drug allergies and medical conditions
  • Name and telephone number for up to three emergency responders.
  • Billing name, address, and phone number.
  • We ask if subscriber smokes as this information is important for the installer going in to the home.
Applicant's Information
 
*Applicant's Full Name (First/Last)
*Applicant's Full Name (First/Last)
Gender     
*Date of Birth
Primary Language
Does the subscriber smoke?   
*What is your current type of home phone service?
     
*Home Telephone Number
*Street Address
*City
*State/Province
*ZIP/Postal Code
Applicant's Personal Health Information
Primary Physician Preferred Hospital
Name (First/Last)
Phone
Hospital Name
Phone
 
Please list all Drug Allergies Please list all Medical Conditions/Diseases
Personal Contact Information
Please list name and contact information of up to three responders in the order of preferred contact.
Responder One
Name (First/Last)
Primary Language
Home Phone
Work Phone/Extension
Cell Phone
Other Phone
Relationship to Applicant
If response is required and you are not available, do you want to be notified?         
Does responder have a key?         
 
Notification Information
Would you like to provide an additional contact to be notified in the event of an incident?
(ie: out of town friend or family member, caregiver, etc.)
    
Billing Information
Please provide where billing information should be sent.
 
*Name (First/Last)
*Street Address
*City
*State/Province
*ZIP/Postal Code
*Home Phone
Other Billing Information
Service Information
Which service would you like?
* For an additional $10 per month the pendant automatically places a call for help if it detects a fall and you're unable to push the button yourself.
Installation Arrangements
Please provide a contact to arrange installation
Installation contact is the same as:





Other Information
Please note any other important information:
Referral Source
Who referred you to the LifeLine Care Service? Name or Agency
Phone