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Philips Lifeline Referral Form

  • Client Information

  • Name * Required
  • Address * Required
  • Best Time to Call: * Required
  • Is the client the primary contact? * Required
  • Client has requested (check all that apply): * Required
  • Funding will be provided by Veteran Affairs Canada? * Required
  • Additional Contact Person

  • Name
  • Best Time to Call:
  • Relationship to Client:
  • Referral Source

  • Referred By Acclaim Health Staff Member: * Required
  • Permissions

  • Consent and Privacy * Required
    By submitting this referral you acknowledge that you have obtained consent from the client named on this form to a) release their personal information to Philips Lifeline b) that the information will be used to contact the prospective subscriber for the purposes of further explaining Lifeline's products and services (there is no obligation to accept any products and services) and c) the client also agrees that Philips Lifeline can share the outcome regarding their decision to take / not take the Lifeline service with you and Acclaim Health.
  • Permission to Submit * Required
    Acclaim Health is committed to individual privacy and has taken reasonable precautions to ensure the security of the information you are submitting through this online form. By clicking "I agree" you are acknowledging that the client has given you permission to submit this referral via the online form, and that you have explained the potential risks inherent in submitting personal information and/or personal health information online.
  • This field is for validation purposes and should be left unchanged.
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