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MePACS Application Form for Personal Alert AssistanceSA (PAASA)

"*" indicates required fields

Your details

Your Name*

First name Last name

Organisation

Your Contact Number*

Your Email

Client Details

First Name*

Last Name*

Date of Birth*

Title*

Client Address

Address Line 1*

Address Line 2

Suburb*

State*

Post Code*

Phone Number*

Email*

Client health information

Does the client have issues with: (tick all that apply)

Falls

Mobility

Hearing

Heart Disease

Speech

Vision

Memory

Allergies

Asthma/Airways

Diabetes T1

Diabetes T2

Other

Emergency Contact Details

Emergency contacts must live within 30 minutes of the client's address and must be willing and able to assist in an emergency.

Emergency Contact 1

First name Last name

Emergency Contact 1 address

Street Address Suburb State Post code

Emergency Contact 1 Email

Emergency Contact 1 Phone Number

Relationship to Client

Does this contact have a spare key?

Yes

No

Emergency Contact 2

Emergency Contact 2 name

First Name Last Name

Emergency Contact 2 Address

Street Address Suburb State Post code

Emergency Contact 2 Email

Emergency Contact 2 Phone Number

Relationship to Client

Does this contact have a spare key?

Yes

No

Approval Details

Equipment Approval Number

Monitoring Approval Number

Personal Alarm Type*

Home Alarm with Falls Pendant

Additional Extras

Daily Call Service: $72 per year

Key Lock: $80 (One-off)

Please tick all that apply

Thank you for your order. One of our team will be in contact with you shortly to confirm your order and take payment.

At MePACS, our goal is to help keep people safe by providing prompt and reliable professional assistance in an emergency.

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Sales enquiries

1800 685 329

sales@mepacs.com.au

Existing clients

1800 451 300 mepacs@mepacs.com.au

Or head to our Contact Us page for more options.

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