LifeFone Emergency Medical Alert Alarm New Subscriber Activation

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New Subscriber Activation

Please fill in the form with information about the subscriber (end-user) of the LifeFone Personal Emergency Response Services.

In order to ensure new subscriber activation, it is important that you complete this form in full. Required fields are in red.

First Name:
Middle Initial:
Last Name:
Street Address 1:
Street Address 2:
Apartment/Unit Number:
Nearest Cross Street:
City:
State/Province:
Zip/Postal Code:
Phone 1:
Phone 2:
Date of birth:
Gender:	F M

Please fill in the following information if you are not the above named subscriber.

Name:
Phone 1:
Phone 2:
Agency (if applicable):
Best time to call:
Email Address:

Responders (in order of priority)
Please include Name, Relationship to the LifeFone Subscriber, Key Holder, Home Phone, Work Phone, Pager and Mobile Phone

Please be sure to include area codes on all phone numbers.

Responder 1
Name:
Relationship:
Keyholder:	Y N
Home:
Work:
Cell:
Pager:
Responder 2
Name:
Relationship:
Keyholder:	Y N
Home:
Work:
Cell:
Pager:
Responder 3
Name:
Relationship:
Keyholder:	Y N
Home:
Work:
Cell:
Pager:
Responder 4
Name:
Relationship:
Keyholder:	Y N
Home:
Work:
Cell:
Pager:
Responder 5
Name:
Relationship:
Keyholder:	Y N
Home:
Work:
Cell:
Pager:
Responder 6
Name:
Relationship:
Keyholder:	Y N
Home:
Work:
Cell:
Pager:

Physician Information

Name:
Street Address:
City:
State:	Zip Code:
Phone:
Hospital Preference
Hospital Name:
Phone:

Medical Conditions None

Physician Prescribed Medications None

Allergies None

Ambulatory

Yes:	without assistance with walker	with cane wheelchair
No:	not ambulatory

Special Instructions
Please include any additional information that would be relevant to the new LifeFone Subscriber's situation (hidden key, insurance info, living will, specific instructions for individual responders.)

Your LifeFone Customer Care Representative's name (if known)

Click the button below to review your information before submitting to LifeFone.