Use this form to activate a LifeFone Medical Alarm. Fields labeled in red are required.

Subscriber Information
First Name   
Middle Initial   
Last Name   
Street Address 1   
Street Address 2   
Apartment/Unit Number   
City   
State/Province   
Zip/Postal Code   
Home Phone   
Mobile Phone   
E-Mail   
Date of Birth (DD/MM/YY)   
Gender   


Caregiver Information
Full Name   
Home Phone   
Mobile Phone   
Agency (if applicable)   
Best time to call   
E-Mail   


RespondersPlease include as much information as possible about the responders. These are people LifeFone will contact in case of an emergency. In addition, please make sure you include the area code for any phone numbers!

Responder #1
Full Name   
Relationship   
Keyholder   Yes No
Street Address   
City   
State/Province   
Zip/Postal Code   
Home Phone   
Mobile Phone   
Work Phone   
Special Instructions
Responder #2
Full Name   
Relationship   
Keyholder   Yes No
Street Address   
City   
State/Province   
Zip/Postal Code   
Home Phone   
Mobile Phone   
Work Phone   
Special Instructions
Responder #3
Full Name   
Relationship   
Keyholder   Yes No
Street Address   
City   
State/Province   
Zip/Postal Code   
Home Phone   
Mobile Phone   
Work Phone   
Special Instructions
Responder #4
Full Name   
Relationship   
Keyholder   Yes No
Street Address   
City   
State/Province   
Zip/Postal Code   
Home Phone   
Mobile Phone   
Work Phone   
Special Instructions
Responder #5
Full Name   
Relationship   
Keyholder   Yes No
Street Address   
City   
State/Province   
Zip/Postal Code   
Home Phone   
Mobile Phone   
Work Phone   
Special Instructions


Physician Information
Full Name   
Street Address   
City   
State/Province   
Zip/Postal Code   
Telephone #   


Hospital Preference
Hospital Name   
Telephone #   


Health InformationPlease separate the following information with commas, so that we can accurately record the subscriber's health information.

Diagnosed Medical Conditions
Diagnosed Allergies
Physician Prescribed Medications


Ambulatory Information
Not Ambulatory
Ambulatory Without Assistance
Ambulatory With Cane
Ambulatory With Walker
Ambulatory With Wheelchair


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



LifeFone Customer Care Representative (If Known)


LifeFone in the News

LifeFone is proud of the recognition we have received from leading healthcare and senior organizations.

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