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ORDER ONLINE

 

MEDICAL ALARM INTERNET ORDER FORM

(USE INTERNET EXPLORER ONLY)

 

YOU CAN ALSO ORDER BY PHONE OR FAX:  Call us toll free at 1-866-661-2537.  You can either place an order by phone or give us your fax number and we will fax the order form to you. Ordering takes about 10 minutes.

Choose A Plan: Monthly, Quarterly or Yearly

 

 

 

 

† All Plans Include Medical Alarm, Personal Button, 24 Hour Monitoring Service, Standard Shipping

 

Select Type of Button: Pendant or Wristband  

The first button is included with all plans. Select your style of button

If you want additional buttons, go to optional accessories..

 

 

 

Pendant (around neck)

 

Wristband

 

 

Select Your Optional Accessories

 

All plans will be billed monthly or a one time charge for Optional Accessories as noted.

 

Automatic Calling Smoke Detector

(90% of residential adult fire causalities were over 65- 39% were asleep)

 

Add $5.95 per month

 

more details.

 

  NO DETECTOR

ONE DETECTOR ($5.95/month)

TWO DETECTORS ($11.90/month)

  THREE DETECTORS ($17.85/month)

  FOUR DETECTORS ($23.80/month)

 


Off Hook Phone Device

One time charge of $19.95 each

(need one for every telephone line)

(absolute necessity)

 

more details

  NO DEVICES

ONE DEVICE ($19.95)

TWO DEVICES (39.90)

  THREE DEVICES ($59.85)

  FOUR DEVICES ($79.80)


Carbon Monoxide Detector

 

Add $5.95 per month

 

 

more details

 

  NO DETECTOR

ONE DETECTOR ($5.95)/month)

TWO DETECTORS ($11.90/month)

  THREE DETECTORS ($17.85/month)

  FOUR DETECTORS ($23.80/month)


 

Medical Information Box

One time charge of  $19.95 each

 

 

more details

 

MEDICAL INFORMATION BOX

(for Emergency Personnel- indicates Medical,

Drug, Doctor, Allergies, etc; Put box on top

of refrigerator)


Combination Lockbox

 

One time charge of $39.95 each

 

Hanging Style

Wall Mount Style (requires installation) 

 

Enter 4 Digit Lockbox Combination   

 

more details                                           

 

 


Extra Pendant Buttons

(includes neck cord)

One time charge of $39.95 each

more details

  NO BUTTON

ONE BUTTONS ($39.95)

TWO BUTTONS ($79.90)

 THREE BUTTONS ($119.85)


Extra Wrist Buttons

(includes wrist strap)

One time charge of $39.95 each

 

 

more details

  NO BUTTON

ONE BUTTONS ($39.95)

TWO BUTTONS ($79.90)

 THREE BUTTONS ($119.85)

 

 

Shipping Choices

 

 

Free Standard Delivery 4-5 Business Days - (New Alarm Customers only) *
2- Day Delivery (Weekends Not Included) $19.95 *
Standard Overnight Delivery $24.95 (Must Order Before 2PM EST) *
 

* Not Available in Alaska or Hawaii - Please call for details

Shipping is Monday through Friday- No delivery on Saturday, Sundays & Holidays

 

 

Client Information  

Information of Person using Medical Alarm:

 

First Name
Last Name
Address 1
Address 2 (apt #)
City
State
Zip Code
County/Township
Phone Number (include Area Code)
Email

 

Medical Information of Client  

 

Date of Birth (mm.dd,yyyy)  / /
Current Medical Conditions:

Heart Problems          

Asthma

Diabetes

 

Seizures

 

I have Special Medical Instructions For Emergency Personnel - Do Not List Medications. (Optional)

(Maximum 350 characters)

 

Is Someone Else Being Monitored In the House?-(2nd Client)  
First Name
Last Name
Relationship
Date of Birth (mm.dd,yyyy)  / /
Current Medical Conditions: Heart Problems 

Asthma

Diabetes

 

Seizures

I have Special Medical Instructions For Emergency Personnel - Do Not List Medications.  (Optional)

(Maximum 350 characters)

 

Information Regarding Client's Home  

Information of Home where Medical Alarm is  Located.

Directions to Client's Home (Be specific)

 

(Maximum 350 characters)

 

Location of Lock Box with House Key (Be specific)

(Maximum 350 characters)

 

Does the Client have internet service? (select one)

Cable

DSL

Dial-Up 56k

No Internet Service

 

What type of phone does the Client have?

 

Touch Tone

Pulse/Rotary Dial

 

 VOIP: If you have VOIP (Voice over Internet Phone), it is unreliable with medical alarm systems. Please call us on our toll free number and we can advise you on your alternatives.

 

 

EMERGENCY CONTACT INFORMATION

 

If we can't hear the Client after the Alarm is Activated?  

If the alarm is activated and our representative is unable to communicate with the client, our representative will attempt to call the residence. If our representative does not receive a response, who do you want them to contact first?

Call Emergency Personnel First (highly recommended)

  Call My Personal Contacts First

If all the personal contacts are unreachable, then our representative will call Emergency Personnel.

 

 

 

 

PERSONAL CONTACTS

 

Your personal contacts are the people you want us to notify in case of an emergency, your family, friends, and neighbors. You should have a minimum of 2 personal contacts, and at least one of them should be able to respond in an emergency. List them in the order you want them called, and we will call them in order until at least one is reached. Do not list 911 numbers  and other emergency numbers, as we obtain these numbers.

 

 

 

 

First Contact To Call

 

 

Name of Personal Contact

Relationship to Client

Calling Order (1 to 5)

Phone numbers to contact  (Include Area Code)

Call

Order

Phone Number

Type Of Phone

1)

2)

3)

Has House Keys

Yes No

In an emergency this person should:

Be Notified   Respond   Both

  

 

Second Contact To Call

 

 

Name of Personal Contact

Relationship to Client

Calling Order (1 to 5)

Phone numbers to contact  (Include Area Code)

Call

Order

Phone Number

Type Of Phone

1)

2)

3)

Has House Keys

Yes No

In an emergency this person should:

Be Notified   Respond   Both

 

 

Third Contact To Call  

 

Name of Personal Contact

Relationship to Client

Calling Order (1 to 5)

Phone numbers to contact  (Include Area Code)

Call

Order

Phone Number

Type Of Phone

1)

2)

3)

Has House Keys

Yes No

In an emergency this person should:

Be Notified   Respond   Both

  

 

Shipping Information  This is the address we will ship the Medical Alarm.

 

  Ship to client's address.

 

First Name
Last Name
Address 1
Address 2 (apt #)
City
State   
Zip Code
County/Township
Phone Number (Include Area Code)
Email

 

 

Person Who Pays Bills

The person who pays bills can be changed at anytime. You can fill out the internet Update Billing section, or call us with our toll free number.

 

 

  Check here if the client will pay for the alarm.

 

First Name
Last Name
Address 1
Address 2 (apt #)
City
State
Zip Code
County/Township
Phone Number (Include Area Code)
Email

 

 

Credit Card Information

 

 

 IMPORTANT: Only show name as it appears on Card:

First Name
Middle Initial (only if on card)
Last Name
Card Type  
Card Number (no dashes or spaces)
Expiration Date /

 

 

Automatic Check Payment Information

IMPORTANT: Only show name as it appears on Check:

First Name
Middle Initial (only if on check)
Last Name
Bank Name
Routing Number (9 digits only)
Account Number
 

 

 

Payment Information can be changed anytime on-line with our Update Billing Section, or you can call us with our toll free number.

 

I (We) have read, understand, and agree to the terms and conditions above. (Required to Purchase)

 

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