Dose Remind Request Form
By submitting the following form you are agreeing to Dose Health's terms and conditions at http://dosehealth.com/terms
YOUR INFORMATION
This is for the person submitting the form
Your First Name *
Your Last Name *
Your Email Address/Phone Number *
CLIENT INFORMATION
This is for the person who will receive the reminder
Client First Name *
Client Last Name *
Client Date of Birth *
MM
/
DD
/
YYYY
Client Phone Number *
REMINDER INFORMATION
Select the method for receiving reminder *
What message should we send? *
Select the days the reminder will be sent
What time(s) should the reminder be sent? *
How often should the reminder be sent until confirmation has been received? (e.g. every 20 minutes) *
If confirmation is not received, how long should the reminder be sent until marking the activity as missed? (e.g. 2 hours) *
What date would you like reminders to start? *
For a non-English message, indicate the preferred language below.
NOTES / ADDITIONAL COMMENTS
If more than one reminder is needed, please put all info below (days of the week, time, message, frequency, and time frame).
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