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Medical Alarm Service Order Form
Please Use Internet Explorer Only
To Order By Phone Call 1-866-581-4540 Hours
Orders received after 4 pm EST will be processed the next business day.

It's Easy To Order - Start By Choosing A Service Plan from the options below.
Your free month of service will be added to the end of your first month, quarter or year choice.

FREE Month will automatically be added to the
end of the billing cycle you choose.
Includes Medical Alarm, Personal Button, 24 Hour Monitoring, Standard Shipping

 

Now Select The Style Of Included Personal Button You Want

The first button is included with your purchase.
Select your personal preference. If you wish to purchase additional buttons go to next step.


Help Button / Wristband
Necklace
    
Wristband

 

Optional Accessories

Secure Lock Box

One time payment of:
Was $39.95 each
Now $19.95 each with new service.

Learn More

Enter a 4-Digit combination for your new lockbox here >>

Extra Personal Button

One time payment of:
Was $39.95 each
Now $19.95 each with new service.

Learn More

  

Voice Extender

One time payment of
$99.00

Learn More

  


Now Choose Shipping For Your Order

- (New Services Only)*

 

Client Information
Provide this information about the person that will be using Alert One.
First Name
Last Name
Address 1
Address 2
City
State
Zip Code
County/Township
Phone
E-Mail


Medical History of Client
Date of Birth: (mm/dd/yyyy)  /   / 
Do you have?
Special Medical Instructions For EMS - Do Not List Medications (Be Specific)
(Max 300 Characters)


Is There An Additional Client In The Home?
First Name
Last Name
Date of Birth: (mm/dd/yyyy)  /   / 
Do you have?

Special Medical Instructions For EMS - Do Not List Medications (Be Specific)
(Max 300 Characters)

Style of personal button for the additional client listed above.




Information About The Clients Residence

This information will be about the residence where the medical alarm will be used.


Directions To The Clients Residence (Be Specific) (Max 300 Characters)

Location of hidden key or lock box (Be Specific) (Max 300 Characters)
 
Does the client have internet service? (select one)
What type of phone service does the client have?


Important: VOIP internet phone service (Voice Over IP) does not meet the customer care standards of Alert One as a satisfactory method of transmitting emergency calls and can be unreliable with any medical alarm system. For safety tips regarding phone service and medical alarms call us at 1-866-581-4540



Emergency Contact Information

Your personal contacts are the family, friends and neighbors you want us to notify in an emergency. You should have at least (2) two personal contacts. Place them in the order you want them called. In an emergency Alert One will call them in order until at least one is reached. Do not include local 9-1-1 information on this form. Alert One will obtain 9-1-1 and other local emergency numbers for you.

If the client is unresponsive?

In the event the client activates their alarm but is unable to communicate with the Alert One operator, the operator will attempt to call the residence. If they do not receive a response who do you want them to contact first. Please note that if personal contacts are unreachable EMS will be dispatched to the home.


 

You should designate at least one personal contact as able to "Respond" in an emergency by selecting the "respond" option below their phone numbers.

Your First Personal Contact
Name
Relationship
Phone numbers for contact one: (Example: 555-555-1212)
Call Order
Phone Number
Type Of Phone
1)
2)
3)
Has House Keys
In an emergency this person should:




Your Second Personal Contact
Name
Relationship
Phone numbers for contact one: (Example: 555-555-1212)
Call Order
Phone Number
Type Of Phone
1)
2)
3)
Has House Keys
In an emergency this person should:




Your Third Personal Contact
Name
Relationship
Phone numbers for contact one: (Example: 555-555-1212)
Call Order
Phone Number
Type Of Phone
1)
2)
3)
Has House Keys
In an emergency this person should:




Your Fourth Personal Contact
Name
Relationship
Phone numbers for contact one: (Example: 555-555-1212)
Call Order
Phone Number
Type Of Phone
1)
2)
3)
Has House Keys
In an emergency this person should:




Your Fifth Personal Contact
Name
Relationship
Phone numbers for contact one: (Example: 555-555-1212)
Call Order
Phone Number
Type Of Phone
1)
2)
3)
Has House Keys
In an emergency this person should:



Shipping Information

This is where we will send the system.

First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Phone
E-Mail

 

Who Will Be Paying For The Service?

This area is where the bill payer information goes. This is the person making today's payment. Bill payer information can be changed for future payments by calling Alert One Customer Service at 1-866-581-4540

First Name
Last Name
Address 1
Address 2
City
State
Zip Code
Phone
E-Mail

 

Payment Option 1 - Credit Card Information
Card Holder Name * >> As Appears On Card
Card Type *
Card Number * No Dashes or Spaces
Expiration Date / *


Payment Option 2 - Automatic Check Payment Information
Name On Account *
Bank Name *
Routing Number * (9-Digits Only)
Account Number *
 

This payment information will be used for future payments. You can change your payment information for future invoices by contacting Alert One Customer Service. 1-866-581-4540

 

Tell Us About Your Visit

 



If someone referred you to Alert One, please let us know so that we may thank them.
Enter their Name/Organization, Complete Address and any comments in the box below.
(Max 300 Characters)

 

" (Required To Purchase)