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Solutions
- PERS
- Vitals
- E3
- Medication Management
Who We Serve
Company
- About Us
- Contact Us
- Careers
- Library

LETS CONNECT

Solutions
- PERS
- Vitals
- E3
- Medication Management
Who We Serve
Company
- About Us
- Contact Us
- Careers
- Library

Solutions
- PERS
- Vitals
- E3
- Medication Management
Who We Serve
Company
- About Us
- Contact Us
- Careers
- Library

Ideal Home Care Services Referral Form

VRI offers a full suite of innovative solutions and connected devices that are reliable and simple to use.

Thank you for choosing VRI

To call in a referral: 800-860-4230, Option 2

Ideal Home Care Services - Referral Form

Case Manager

Name(Required)

First Last

Email(Required)

Phone(Required)

Client Information

Name(Required)

First Last

State ID(Required)

Date of Birth(Required)

Month

Day

Year

Address

Street Address Apartment/Suite # City State / Province / Region ZIP / Postal Code

Phone 1(Required)

Phone 1 Type(Required)

Phone 2

Phone 2 Type

If client is non-english speaking, preferred language:

Can client be contacted directly?

Yes

Client's Contacts

Contact Type

This is the Preferred Contact

Contact Name

First Last

Contact Phone Type

Phone

Notes or additional contacts

Type of Equipment Needed

Personal Emergency Response Systems (PERS)

Mobile - $30/Month

Mobile with Fall Detection - $40/month

In-Home Cell - $30/Month

In-Home Landline - $24/Month

Fall Detection - $5/Month

Lockbox - Complimentary

Locked Medication Management Devices

Medication Dispenser (monitored) - $30/Month

Medication Dispenser (non-monitored) - $25/Month

Who will handle the medication for this client?

First Last

Medication Contact Phone

Additional Notes

Is there any additional information regarding this client that would assist us with the installation?

Is there a delayed installation date?

Month

Day

Year

account support team.

Connor McNamara

Territory Manager
Phone: 857-331-5566
Email: [email protected]

Jill Sweny

Accounts Support Coordinator
Phone: 937-550-1592
Email: [email protected]

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HOME

ABOUT

SOLUTIONS

PERS
Vitals
E3
Med Management

RESOURCES

Contact
Library

CAREERS

Careers

Facebook Linkedin Twitter

Terms & Conditions
Privacy Notice
Accessibility
Ethics
Service Animal Policy

Terms & Conditions
Privacy Notice
Accessibility
Ethics
Service Animal Policy