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About Us
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Mobile System
Indoor System
Retirement Village Solutions
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About Us
Our Products
Mobile System
Indoor System
Retirement Village Solutions
Contact Us
Book A Demonstration
AidCall
Application
Thank you for your interest in AidCall 24/7.
Please complete this form to get to know you better.
Device Type
Device Type*
Mobile System
Indoor System
Retirement Village Solutions
Device ID
First Name
Last Name
Phone Number
Alternative Phone Number
Email Address
Date Of Birth
Language
Language*
Afrikaans
English
Xhosa
Zulu
Tswana
Other
Gender
Gender*
Male
Female
Marital Status
Marital Status
Single
Married
Widowed
Divorced
Address
Type Of Residence
Type Of Residence
House
Flat / Apartment
Complex
Retirement Village
Complex Name (If Applicable)
City
Zip/Postal Code
Do You Have A Key Box
Do You Have A Key Box
Yes
No
Key Box Number
Medical Aid Name
Medical Aid Number
Description of Mobility
Description of Mobility
Good
Fair
Poor
Medical Conditions
Medication related to condition
Please list all know allergies
Do you use blood thinners?
Do You Use Blood Thinners?
Yes
No
Blood Type
Blood Type
A positive (A+)
A negative (A-)
B positive (B+)
B negative (B-)
AB positive (AB+)
AB negative (AB-)
O positive (O+)
O negative (O-)
Unknown
Number Emergency Contacts
Number of Emergency Contacts
1 Emergency Contact
2 Emergency Contacts
3 Emergency Contacts
Emergency Contact 1 Information
Contact Name
Keyholder Name
Relationship
Suburb
Province
Home Telephone
Work Telephone
Cellphone Number
Email Address
Emergency Contact 2 Information
Contact Name
Keyholder Name
Relationship
Suburb
Province
Home Telephone
Work Telephone
Cellphone Number
Email Address
Emergency Contact 3 Information
Contact Name
Keyholder Name
Relationship
Suburb
Province
Home Telephone
Work Telephone
Cellphone Number
Email Address
Comments
Consent
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Terms & Conditions
and consent to the processing of my personal data for marketing and profiling purposes.
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