FYLLIS PRACTICE PAGE

REP

Short answer

------------------------------------------CALLER-----------------------------------------------

First name

Last name

CALLER Email*

CALLER Home Phone

CALLER Cell Phone

---------------------------------------------USER-----------------------------------------------

USER First Name

Short answer

USER Home Phone

USER Cell Phone

Multi-line address

Country/Region

Address

City

Zip / Postal code

Long answer

Short answer

-------------------------------------PAL CHOICE #1------------------------------------------

PAL CHOICE #1

PAL STAY SAFE SMART WATCH - Product Cost$0

3 Month Monitoring ($40/month)

$120

One Time Setup Fee to Program

$149

-------------------------------------PAL CHOICE #2------------------------------------------

PAL CHOICE #2

PAL ON-THE-GO SOS PENDANT - Product Cost$0

3 Month Monitoring ($40/month)

$120

One Time Setup Fee to Program

$119

-------------------------------------PAL CHOICE #3------------------------------------------

PAL CHOICE #3

IN-HOME HEALTH SYSTEM with Pendant or Wrist Button - Product Cost$0

3 Month Monitoring ($40/month)

$120

One Time Setup Fee to Program

$119

---------------------------ADDITIONAL MONTHLY OPTION---------------------------

FALL DETECT

Set up$0

3 month fee Fall Detect ($10/month)

$30

MONTHLY INSURANCE

Set Up$0

3 month fee Insurance ($5/month)

$15

---------------------------------------PAL COMBO-------------------------------------------

PAL COMBO

CUSTOMIZED BUNDLE$0

3 MONTH BUNDLE MONITORING

One Time Setup Fee to Program

WHAT'S IN YOUR USER 1 BUNDLE ? [NAME? UNIT? FALL DETECT? INSURANCE?

WHAT'S IN YOUR USER 2 BUNDLE ? [NAME? UNIT? FALL DETECT? INSURANCE?