Customer Details

How Are You Funding Your Alarm? *

Private Client Funding Other

What Is The Name Of The Funding Organisation? *

Title *

First Name *

Last Name *

Do you have a preferred name? *

YesNo

What is your preferred name?

Date of Birth *

Address Details

Address Details *

Street Address Line 1 *Street Address Line 2

City *

State *

Postcode *

If this address has an identifier such as a building name or community name, please advise in Address Line 1

Do you live alone?

YesNo

Access Details

Do you have a key safe or keep a key outside to access your home? *

YesNo

What is the key safe code if applicable?

Where is the key located?

Contact Details

Mobile Phone Numbere.g. 0491 570 737

Landline Phone Numbere.g. 07 1234 5678

Email Address

Medical Information

Medical Condition(s)?We are only looking for information that you think will be important for a paramedic to know in the event they are required to attend.

Life dependent medication(s) including blood thinners if any?We are only looking for information that you think will be important for a paramedic to know in the event they are required to attend.

Allergies?We are only looking for information that you think will be important for a paramedic to know in the event they are required to attend.

Approximate weight? We pass this information on to the paramedics to help in their assessment to best help you.

Emergency Contacts

The ideal emergency contact is someone who lives close to you, is likely contactable at any time, they know who else to let know about your situation and they have access to your property when it is needed. At least two emergency contacts are typical.

Emergency Contact #1 Name *

Emergency Contact #1 Relationship *

Is Emergency Contact #1 Next of Kin? *

YesNo

Emergency Contact #1 Phone Numbers *e.g. 07 1234 5678 or 0491 570 737

Email Address for Emergency Contact #1

Emergency Contact #1 travel time to your place in minutes (typically)? *

Do you want to add a second emergency contact? *

YesNo

Emergency Contact #2 Name

Emergency Contact #2 Relationship *

Is Emergency Contact #2 a Next of Kin?

YesNo

Emergency Contact #2 Phone Numberse.g. 07 1234 5678 or 0491 570 737

Email Address for Emergency Contact #2

Emergency Contact #2 travel time to your place (typically)?

Do you want to add a third emergency contact?

YesNo

Emergency Contact #3

Emergency Contact #3 Relationship *

Is Emergency Contact # 3 a Next of Kin?

YesNo

Emergency Contact #3 Phone Numberse.g. 07 1234 5678 or 0491 570 737

Email Address for Emergency Contact #3

Emergency Contact #3 travel time to your place in minutes (typically)?

Permissions

I have read and agree to Tunstall's: Personal Emergency Response Service Authorisation and Privacy Statement

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