ATS GPS Intake Form

Submitter Information

The person filling out this form.

Submitter Name *

Please enter your name.

Email Address *

Please enter a valid email address.

Comments (optional)

Ship This Unit — Signature Required

Ship this unit, signature required, to the following address. All fields are required.

Name *

Please enter the name to ship to.

Street *

Please enter the street address.

City *

Required.

State *

Required.

ZIP *

Required.

Please see the information below that will need to be filled out concerning your clients. If a customer isn't sure of some of the information needed below, like blood type, it's fine to leave it out.

Client / User

Name, address, and best contact number for the client/user.

Client Name *

Please enter the client's name.

Case ID (if known)

Street Address *

Please enter the street address.

City *

Required.

State *

Required.

ZIP *

Required.

Best Contact Number *

Please enter a contact number.

Emergency Call Order

Choose whether 911 is called first, then list who should be contacted.

Call 911 first. After 911 is called, alert the people below that there was an emergency. Do NOT call 911 first. Call the people below in the order listed.

Home Access

Hidden Key Location

File of Life Located

Medical Information

Name

Date of Birth

Blood Type Medical History Allergies

Physician

Physician Phone

Preferred Hospital

City

State

Phone

Save & Send

Saves a copy to your device and opens your email program with everything filled in, addressed to Questions@ATSCARES.COM. Just press Send in your email.

Email doesn't open? Use Copy details and paste them into an email to Questions@ATSCARES.COM.