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Installation
Installation
Subscriber Activation
The Philips Medication Dispenser Subscriber Activation Form and Services Agreement
must be sent to the Support Center before the dispenser is installed. This form
provides important information about:
• Caregivers–peoplewhowillbenotiedincaseofmisseddosesoranyproblems
• Medicationdeliveryschedule
• Messages–twotypesofwhichareannouncedanddisplayedbythe
Philips Medication Dispenser:
1. Messages that accompany dispensed medication cups (e.g., “Take meds with food”)
2. Reminder messages that occur between medication doses (e.g., “Time for
your insulin” and “Check blood pressure”)
Fax the completed Subscriber Activation Form
and Services Agreement to Philips at least one
day before the dispenser installation. If you
have any questions about the form or need
to make any changes, please call the Support
Center.
Philips Lifeline Medication Dispenser
Subscriber Activation Form and Services Agreement
Program Name ____________________________ Program Code ________ Client Type: ❏GSD ❏PP Order: ❏PERS ❏Med
Medication Dispenser Unit Serial Number __________________________________________________________________
Subscriber Name ____________________________________________________ Date of Birth _____________________
Street Address ______________________________________________________________________ Gender: M F
City _________________________________________ State ___________________________ Zip Code ____________
Phone Number with Area Code ____________________________ Time Zone: ATL EST CST MST PST AST HI
Phone Service Type: ❏ Standard ❏ Internet ❏ Unknown
To Call In: 1-888-632-3261 • Fax Form to: 1-888-632-3267
111 Lawrence Street • Framingham, MA • 01702-8156 www.lifelinesystems.com
Important: Please fax prior to installation with unit serial number to 1-888-632-3267
p/n 0940570, Rev. 01
Caregiver/Client Signature _______________________________________________ Phone Number _____________________________
Installer Signature _____________________________________________________ Date Installed ______________________________
❏ Installer did not handle medications ❏ Schedule displayed on dispenser during loading process is accurate
By signing this Form and Agreement, I hereby (a) conrm the accuracy and completeness of the information provided in the Form
above, (b) acknowledge that I have been provided with, have read and understand the “Terms and Conditions” that govern this
Agreement, and (c) conrm that this Agreement accurately states the products and services I expect to receive hereunder.
Subscriber Signature: ________________________________ Date Signed: _________________________
Medication Dose Schedule
Dose Dose Time
1 _____:_____AM/PM
2 _____:_____AM/PM
3 _____:_____AM/PM
4 _____:_____AM/PM
5 _____:_____AM/PM
6 _____:_____AM/PM
Message Reminder Schedule (Use Key)
Message Time Message #
_____:_____AM/PM #
_____:_____AM/PM #
_____:_____AM/PM #
_____:_____AM/PM #
_____:_____AM/PM #
_____:_____AM/PM #
Monday - Sunday: Yes/No,
If NO, please explain:
_______________________
_______________________
_______________________
Medication Message List
0 No Message 12 Use Mouth Inhaler
1 Time for your insulin 13 Take on empty stomach
2 Take meds with food 14 No alcohol with meds
3 May cause drowsiness 15 Don’t drive with this med
4 No food w/ meds for 2 hours 16 Take meds with juice
5 Take extra uids w/ meds 17 Take meds with milk
6 Change Catapress Patch 18 Time for your eyedrops
7 Change Estrogen Patch 19 Check blood sugar level
8 Change Duragesic Patch 20 Check blood pressure
9 Put on Nitro Patch (Note 1) 21 Use your nebulizer
10 Remove Nitro Patch (Note 1) 22 Remember your meal
11 Use Nasal Spray 23 Take your liquid meds (Note 2)
Note 1: Message is “Change Nitro Patch” on some machines
Note 2: Message not available on all machines
Monday - Sunday: Yes/No,
If NO, please explain:
__________________________
__________________________
__________________________
Caregiver Information If a dosage is missed by the user, the unit will call caregivers in the following order:
Phone Number ____________________________________ Relationship to User _________________________________
Caregiver Name ___________________________________________ Need to dial area code from user phone? Y N
Phone Number ____________________________________ Relationship to User _________________________________
Caregiver Name ___________________________________________ Need to dial area code from user phone? Y N
Phone Number ____________________________________ Relationship to User _________________________________
Caregiver Name ___________________________________________ Need to dial area code from user phone? Y N
Phone Number ____________________________________ Relationship to User _________________________________
Caregiver Name ___________________________________________ Need to dial area code from user phone? Y N
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