User Guide

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USER & CAREGIVER WORKSHEET Interacative Medical Developments
Please use this form to provide user and caregiver contact information prior to calling the Support Center. When this is
completed, either Fax [phone]), call in (1-877-472-9037) or mail this information.
USER INFORMATION
MD.2 Serial Number: (The serial number is located on the label inside the locked door.)
User Name: Date of Birth:
User Street Address: Gender: F M
User City: State: Zip:
User Home Phone Number: User Time Zone:
ATL EST CST MST PST AST HI
FAX Number: Email:
When would you like to schedule the set up of the MD.2? ___________________________
(You should plan to schedule the set up at a time when you will be at the user’s home and ready to install and load the machine with medications.)
Caregiver # 1 Relationship to User:
Address City: State: Zip:
Phone Number (exactly as dialed from patient’s phone):
FAX Number: Email:
Caregiver # 2 Relationship to User:
Address City: State: Zip:
Phone Number (exactly as dialed from patient’s phone):
FAX Number: Email:
Caregiver # 3 Relationship to User:
Address City: State: Zip:
Phone Number (exactly as dialed from patient’s phone):
FAX Number: Email:
Caregiver # 4 Relationship to User:
Address City: State: Zip:
Phone Number (exactly as dialed from patient’s phone):
FAX Number: Email:
CAREGIVER INFORMATION
If a dosage is missed by the user, the MD.2 will call caregivers in the following order.