New LifeGuardianPro™ Subscriber Order Form

Sign-up Online Here and Your LifeGuardian Medical Alarm System Ships Next Business Day!

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

If you prefer, click here to print out and FAX your New Subscriber Enrollment 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 or update your information at no charge for as long as you subscribe.

Please Note: * Indicates required field.

1. SUBSCRIBER INFORMATION
*Subscriber (User) Name:
*Physical Address:
Apartment/Unit #:
Nearest Cross Street:
*City
*State:
*Zip Code:
*Telephone Number: (Please Include Area Code)
How Did You Hear About Us?
Authorized Provider ID#:
2. PROGRAM SELECTED (Choose One)*
LifeGuardianPro™ Rental Plan
Rental/Quarterly Plan - Rent a LifeGuardianPro™ system for only $49/mo. - paid quarterly
3. EQUIPMENT RENTAL & ACCOUNT ACTIVATION
A credit card is required for rental & account activation.
*Credit Card
*Name On Card
*Card Number:
*Expiration Date:
*Card CVN Number  (3-4 Digit Security Code On Back)
4. BILLING INSTRUCTIONS
* Bill To Subscriber                 Bill To Another (complete below)
Full Name:
Billing Address:
City:
State:
Zip Code:
Phone Number:
5. MONITORING SERVICE PAYMENT METHOD (Choose One)
:
Credit 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:
6. DELIVERY INSTRUCTIONS
*         
Delivery Name:
Delivery Address:
City:
State:
Zip Code:
Phone Number:
Delivery Instructions:
7. RECOMMENDED PRODUCTS & SERVICES
Key Safe Lock Box ($39) - Exterior lockable safe for quick, secure key access.
Extra Wireless Help Button ($4 each/month) - Includes pendant, wristband & clip.
Wireless Wall/Bath/Hallway Help Button ($4 each/month) - Mount anywhere in the home.
Wireless Smoke Detector ($8 each/month)) - Reports smoke/fire to monitoring center.
Wireless CO2 Detector ($8 each/month) - Reports presense of CO2 to monitoring center.
24 Hour Activity Assurance Monitor($8 each/month) - Includes wireless motion detector..
Priority Mail Service ($40) - Shipped next business day by USPS Priority Mail
Expedited Service ($99) - Next day account set-up & FedEx Next Day Service delivery.
8. APPROVAL AND ACCEPTANCE

Thank you for choosing a LifeGuardianPro™ Medical Alarm System. I hereby authorize LifeGuardian Technologies, LLC or its assignee, Monitoring Services, to commence automatic bank account deductions (EFT) or submit credit card charges based upon the Payment Method that I selected above. I understand the quarterly service plan selected above will renew automatically until I cancel this authorization by delivering written notice of cancellation and return the rental equipment to LifeGuardian Technologies, LLC no less than 30 days in advance of the next billing period. I understand and accept that I have up to thirty days from delivery to return my new LifeGuardian system without any cost or obligation.

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