Medical Alarm System

Lifewatch USA Medical Alarm Service Order Form

Plan 2 - Two-Way Voice Medical Alert System

To Order By Phone Call 1-800-716-1433

Orders received after 4 pm EST will be processed the next business day.

Congratulations! Thank You for choosing Lifewatch for your medical alert system.
Your Choice was Plan 2
TWO-WAY VOICE MEDICAL ALERT SYSTEM
Included
$24.95 per month
Billed Quarterly
Totalling $74.85 for 3 months service
Medical Alarm / Alert and Monthly Monitoring Included!


Now Select The Style Of Included Personal Button You Want

This button is included with your rental or purchase. Select your personal preference. If you wish to purchase additional buttons go to next step.


Pendant / Button Style

Alert Pendants

Necklace Button - Hangs on a 32" adjustable necklace (Recommended)

We also offer choices of materials, sizes, shapes and colors.
Call 1-800-716-1433 for more infomation.

Medical Alert Wristband Wristband Button - Comes on a plastic Comfortable watchband

We also offer choices of materials, sizes, shapes and colors.
Call 1-800-716-1433 for more infomation.

Optional Accessories

Lock Box $39.95 each

Medical Alarms		 Lockboxes

(No need to call neighbors or worry about broken doors)

*Combination For Lock Box (Four Digits Only)


Extra Personal Button
$2.99 per month


Purchase For $39.95

Order Extra Buttons


$2.99 extra-each month per
Necklace Button
$2.99 extra-each month per
Wristband Button

$39.95 each extra Necklace Button
$39.95 each extra
Wristband Button
 

Shipping for your Order.

Free Standard Delivery 3-5 Days
    Priority Air Delivery $19.95
Lifewatch - USA ships orders Monday thru Friday.

Who is filling out this form?
Relationship:
*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip Code:
*Phone Number:
E-mail:

This is the person who will be signing the paperwork, and who will be contacted about any issues with the medical alarm service.

You can select a different person for billing below if necessary. If you don't want to be responsible, the User of the system's name should be entered here. They then will be the Client/User.


Who will be the User of the medical alarm?

 Same as Above
*First Name:
*Last Name:
First Name 2:
Last Name 2:
*Address:
*City:
*State:
*Zip Code:
*Phone Number:
2nd Line Number:
E-mail:
   
Date of Birth: (YYYY-MM-DD)
   
County/Township:
Cross Street:
Complex Name:

Client's Medical History

Do you have?
Heart History
Asthma
Diabetes
Parkinson's
Glaucoma
Dementia
Falls
Other
Special Medical Instructions For EMS - Do Not List Medications (Be Specific)
(Max 300 Characters)

Hearing and Vision
- How is the Client's hearing?

Can't hear Poor Good

- How is the Client's voice?

Can't speak Soft Loud

Tell us about the Client's home
- Type style of home?

House Apartment Condo Assisted Living

- Approximated Sq. footage of home?

 1000  2000  3000+

- How many floors in the home?

1 2 3 and above

Phone Information

- What type of dial tone does the Client have?
Touch Tone Rotary / Pluse Dial


- What type of phone service does the Client have?
Land Line DSL VOIP / Cable

- Do you have to dial 9 to dial out?
Yes No
 

 

 

 

For any additional User fill out "First Name 2" and "Last Name 2". There will be a one time charge of $39.95 for the extra button for the second User of the system.




Second phone number must ring the same User residence or User address as the first phone number.

 

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Response Information

How will the paramedics get into the home?

Call a key holder from the responder list
We will use our own lockbox or have a key hidden
Location (be sure to tell us your combination):
$39.95 Purchase a lockbox
Location:

* During an emergency if we receive no
response we notify 911 first, unless otherwise told.

* YOUR PERMISSION IS ALWAYS GIVEN TO EMERGENCY PERSONNEL
TO FORCE ENTRY INTO THE HOME IF NO KEY IS AVAILABLE
AT THE TIME OF THE EMERGENCY.

 

 

 

 

 

Responder 1
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both

Responder 2
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both

Responder 3
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both

Responder 4
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both

Responder 5
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both

Responder 6
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both

Responder 7
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both

Responder 8
Full Name:
Relationship:
*Phone Number:
Ext:
E-mail:
Key Holder:
Notify
Respond
Both


We will call from the list in geographical order .
We will go down the list until one person is reached.

Choose Your Price Plan


 

 

 $19.95 Per Month
Billed at $239.40 per year
 


 

 

 $24.95 Per Month
Paid Quarterly
Billed at $74.85 for 3 months
 


 

 

$12.95 Per Month
Purchase Option
$189.00 for the unit +
$156.00 for the first year of service Total $356.00

Second Year Only $155.40 
 

Shipping Information
To the address of the person ordering the system.
To the address of the person using the system.
Neither of the above. Ship to the address entered below.

*First Name:
*Last Name:
*Address:
*City:
*State:
*Zip Code:
*Phone Number:
E-mail:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Paying for the Service

If Paying by Credit Card
Bill the Credit Card given below.

Select Card Type:
Account Number:
Expiration Date:

You will see a charge from Lifewatch-USA.com on your statement
 

If Paying by Check

 

 

 

 

 

 

 

 

 

 

 

 

 


 

Electronic Check Same as Above
 
Routing Number Account Number
Name of Bank