Submission of this form means you agree to all the terms and conditions of the e-pill pager medical reminder service agreement. Please mail or fax form to:

CUSTOMER INFORMATION:

FIRST NAME.....:___________________________________________________

MIDDLE NAME....:___________________________________________________

LAST NAME......:___________________________________________________

ADDRESS.........:___________________________________________________

CITY/STATE/ZIP..:__________________ ______ ______________


My TIMEZONE....: _____________

DATE SUBMITTED: _______________

SIGNATURE (required): ________________________________

TELEPHONE:

HOME: ________________________________

WORK: ________________________________

MY PAGER: Alphanumeric , Numeric , PCS , MessageWatch , Beepwear ( circle one )

PAGING SERVICE (Company name): _________________________________

PAGER I.D.(Cap Code or ID Code): ________________________________

PAGER DIAL-UP 800# ("modem number"): ____________________________

Maximum Characters Displayed(for ALPHA PAGERS only): ________

For ALPHA PAGERS:
/Time of day /Medication /Strength(mg)/Frequency: (Daily, Weekly, Every MONday etc./
Example 08:00 am / DIFLUCAN / 1TABx100MG /Daily


1___________________________________________________________

2__________________________________________________________

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9__________________________________________________________

10________________________________________________________


If you have more - just continue the list on a separate page
For NUMERIC PAGERS:Time/Code(Must be a numeric character e.g. "08:00 am /222")
1__________________________________________________________
2__________________________________________________________
3__________________________________________________________
4__________________________________________________________
5__________________________________________________________
6__________________________________________________________
7__________________________________________________________
8__________________________________________________________
9__________________________________________________________
10__________________________________________________________
Please mail or fax form to: