Amazing LifeGuardian Pro Medical alarm And Panic Button Systems
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Proud Member/Supporter Of:
LifeGuardian medical alarm systems are a proud member of AARP

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LifeGuardian Medical Alarms is a proud supporter of the American Society on Aging

LifeGuardian Medical Alarm Systems have been showcased on national television & news programs

LifeGuardian Medical Alarm Systems is a UL listed monitoring facility and home equipment

Buy with confidence from LifeGuardian medical alarm systems
New LifeGuardian Pro™ Subscriber Order Form

Sign-up Online Here and Your LifeGuardian Pro™ Ships Tomorrow!

Please take a few minutes to complete the New Subscriber Information Form and your order will be transmitted electronically direct to the LifeGuardian Medical Customer Service office.

If you prefer, click here to print out and FAX your New Subscriber Information Form.

For fastest sign-up, simply complete this order form and you're order will be submitted immediately. Don't have all the information right now? Remember...you can simply provide billing and shipping information today and you can quickly and easily add/update your information at no charge for as long as you subscribe.

Please Note: * Indicates required field.

1. SUBSCRIBER INFORMATION
New Subscriber Account   Update Subscriber Information   
*Subscriber (User) Name:
*Street (Physical) Address:
Apartment/Unit #:
Nearest Cross Street:
*City
*State:
*Zip Code:
*Telephone Number: (Please Include Area Code)
Location of Hide-A-Key :
Key Safe Combination:
Property Access Code:
How Did You Hear About Us?
Senior Special Offer Yes! (Save $160 If You Order This Month)
 
2. CRITICAL MEDICAL INFORMATION
Date of Birth:
Blood Type:
Preferred Hospital:
Current Medical Conditions:
Required Medications:
Known Allergies:
Special Instructions:
 
3. EMERGENCY EMAIL / TEXT MESSAGE LIST (3 Maximum)
   
Contact #1 Name
Contact #1 Email Address
   
Contact #2 Name
Contact #2 Email Address
   
Contact #3 Name
Contact #3 Email Address
 
3. EMERGENCY TELEPHONE CALL LIST
Contact #1  
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location: (Home/Office/Cell)
Relationship to Subscriber: (Family/Friend/Neighbor)
Contact Has a Property Key?
Contact #2  
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location: (Home/Office/Cell)
Relationship To Subscriber: (Family/Friend/Neighbor)
Contact Has a Property Key?
Contact #3  
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location: (Home/Office/Cell)
Relationship To Subscriber: (Family/Friend/Neighbor)
Contact Has a Property Key?
Contact #4  
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location: (Home/Office/Cell)
Relationship To Subscriber: (Family/Friend/Neighbor)
Contact Has a Property Key?
Contact #5  
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location: (Home/Office/Cell)
Relationship To Subscriber: (Family/Friend/Neighbor)
Contact Has a Property Key?
Contact #6  
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location: (Home/Office/Cell)
Relationship To Subscriber: (Family/Friend/Neighbor)
Contact Has a Property Key?
 
4. PROGRAM SELECTED (Choose One)
LifeGuardian Pro™ Purchase Plans
  Purchase/Annual Plan - Purchase for $249. Monitoring is $29.95/mo paid yearly.
  Purchase/Quarterly - Purchase for $249. Monitoring is $34.95/mo paid quarterly.
  Purchase/Monthly Plan - Purchase for $249. Monitoring is $39.95/mo paid monthly.
LifeGuardian Pro™ Rental Plans
  Rental/Annual Plan - Rent a LifeGuardian system for only $39.95/mo. paid annually.
  Rental/Quarterly Plan  - Rent a LifeGuardian system for only $44.95/mo. paid quarterly
  Rental/Monthly Plan  - Rent a LifeGuardian system for only $49.95/mo. paid monthly
 
5. EQUIPMENT PURCHASE & RENTAL DEPOSIT
A credit card is required for equipment purchase & account activation.
*Credit Card   
*Name On Card
*Card Number:
*Expiration Date:
*Card CVN Number (3-4 Digit Security Code On Back)
   
6. BILLING INSTRUCTIONS
*Bill To Subscriber                  Bill To Another (complete below)
Full Name:
Billing Address:
City:
State:
Zip Code:
Phone Number:
 
6. MONITORING SERVICE PAYMENT METHOD (Choose One)
Bill to Card Above  
OR
Bill To Another Card
Name On Card
Card Number:
Expiration Date:
OR
Deduct From Checking Account (Please FAX a voided check to 800-209-3813)
     Bank Name:
     Account Number:
     Routing Number:
 
7. DELIVERY INSTRUCTIONS
*Deliver To Subscriber Address    Deliver To Billing Address    Other:
Delivery Name:
Delivery Address:
City:
State:
Zip Code:
Phone Number:
Delivery Instructions:
 
8. OPTIONAL PRODUCTS & SERVICES
MasterLock Key Safe ($69 each) - Exterior lockable safe for quick, secure key access.
Expedited Service ($69) - Next day account set-up & USPS Express Mail delivery.
Wireless Smoke Detector ($69 each) - Reports smoke/fire to monitoring center.
Extra Wireless Help Button ($69 each) - Includes pendant, wristband & clip.
 
9. APPROVAL AND ACCEPTANCE

I confirm that the above information is true and correct. By activating and testing the system, subscriber and/or Subscriber’s legal representative(s) acknowledge that they have read, understand and accept the terms and conditions of the LifeGuardian Pro™ Service Agreement. If electronic billing instructions are selected above, I authorize Clayton Communications, Inc. or its authorized representative "Monitoring Services", to make electronic fund transfers in the amount specified from my bank account (include a copy of a voided check) or credit card account. I have been given the opportunity to read and make a copy this Agreement prior to activating my LifeGuardian account.

*Agreement Acceptance I Accept The LifeGuardian Service Agreement
*Accepted By (Type Name):
*Date Completed:
*Phone Number:
*Email Address
Referred By:
Referrer's Phone Number:

*AARP® Product Report: Linear Medical Alarm Equipment Ranked #1 -- PERS (Personal Emergency Response Systems / Medical Alarms and Medical Alert Alarm Systems) was produced by the American Association of Retired Persons as an educational service to members and other older persons. April 1992 No.1 Vol.2

LifeGuardian Medical Alarm Systems is a respected supporter of leading industry associations.

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