Medical Alarm Service, Medical Alarm Monitoring

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Lifewatch USA Medical Alarm Service Order Form

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.
Your Choice was:

LifeWatch USA for Total Protection

Total price $29.99/month

This Plan includes:
• Free Medilok door lock ($40 value)
• Free remote phone answering from pendant ($60/yr. value)
• Free daily wellness check ($60/yr. value)

Now Select The Style Of Included Personal Button You Want

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

Pendant / Button Style
		Necklace Button – (Recommended) Hangs on a 32" adjustable necklace We also offer choices of materials, sizes, shapes and colors. Call 1-800-716-1433 for more information.

		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 information.

Optional Accessories

Lockbox –
$3 per month or
Purchase For $39.95

Included w/ Total Protection Plan

$3 per month

Purchase $39.95

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

*Combination For Lock Box
(Four Digits Only)

Please fill out

Extra Personal Button –
$2.99 per month or
Purchase For $49.95

Order Extra Buttons

	$2.99 extra-each month per Necklace Button
	$2.99 extra-each month per Wristband Button
	$49.95 each extra Necklace Button
	$49.95 each extra Wristband Button

Away from Home "Protection" Card – Included

Each card is personalized with individual identification number
24 hour 800 emergency telephone number to retrieve medical data from a live EMT certified operator
Having a Lifewatch Medical ID Card can provide crucial information to emergency responders even when you are unable to.

Smoke Detectors –
$5.00 per month for Smoke Detector

Order

Yes

Quantity

Carbon Monoxide Detectors –
$5.00 per month for Carbon Monoxide Detector

Order

Yes

Quantity

Shipping & Activation for your Order

Activation – $50 (waived with Total Protection Plan)

Free Standard Delivery 3-5 Days

Priority Air Delivery & Handling (1-3 Days) $19.95

Lifewatch - USA ships orders Monday thru Friday.

Who will be the User of the medical alarm?

*First Name:
*Last Name:
First Name 2:
Last Name 2:
*Address:
*City:
*State:
*Zip Code:
*Phone Number:
2nd Line Number:
E-mail:

Cross Street:

Phone Information

What type of dial tone does the Client have?
Touch Tone Rotary / Pulse 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. We will go down the list until one person is reached.

Response Information

How will the paramedics get into the home?

	INCLUDED IN PROGRAM 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 – Iincluded free w/ Total Protection Plan 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.

To fill out responder information, please click on the link below. This step is optional, as paperwork will be included with your shipment. Please send the completed form to customerservice@lifewatch-usa.com.

Billing Information

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

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

Shipping Information

	Same as billing address.
	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:

I agree to the Lifewatch USA Terms and Conditions.