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to Mountain Parks Electric
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Life Support System Notice
LIFE SUPPORT SYSTEM NOTICE
IN KEEPING OUR RECORDS CURRENT, MOUNTAIN PARKS ELECTRIC, INC. NEEDS TO KNOW
If you or a member of your household are dependent on any type of Life Support equipment, please notify our office with the proper information.
YOUR ACCOUNT NUMBER____________________
METER
NUMBER__________
YOUR NAME____________________________________ DATE__________________
YOUR PHYSICAL ADDRESS______________________________________________
YOUR MAILING ADDRESS_______________________________________________
CITY_______________________ STATE________ ZIP CODE___________________
PHONE NUMBER TO CALL IN CASE OF OUTAGE________ - ________ - ________
NAME AND TELEPHONE NUMBER OF A RELATIVE OR FRIEND
________________________________________________________________________
NAME OF PATIENT______________________________________________________
PLEASE STATE FORM OF LIFE SUPPORT SYSTEM USED
_____OXYGEN CONCENTRATOR
_____SIDS
MONITOR
_____AIR COMPRESSOR
_____KIDNEY DIALYSIS
_____OTHER (PLEASE
SPECIFY)___________________________________
________________________________________________________________________________________________________________________________________________
DO YOU HAVE ANY BACK-UP OR PORTABLE EQUIPMENT FOR THE SYSTEM YOU INCIATED ABOVE? _____ YES _____ NO
COMMENTS:___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Please mail this form to:
Mountain Parks Electric, Inc.
321
W. Agate Avenue P. O. Box 170
Granby, CO. 80446-0170