New LifeGuardianPRO™ Enrollment Form

Sign-up Online Here Before 12:00 noon PST and Your LifeGuardian 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 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 or update your information at no charge for as long as you subscribe.

Please Note: * Indicates required field.

1. SUBSCRIBER INFORMATION
Provider ID Number Or Name:
*Subscriber (User) Name:
*Physical Address:
Apartment/Unit #:
Nearest Cross Street:
*City
*State:
*Zip Code:
*Telephone Number: (Please Include Area Code)
Who Is Your Long Distance Company :
Location of Hide-A-Key :
Key Safe Combination:
Property Access Code:
How Did You Hear About Us?
LifeGuardian Representative:
Promo or Coupon Code:
4. PROGRAM SELECTED*
A complete LifeGuardianPro Medical Alarm System:
Quarterly Rental Plan: Only $44 / month - paid quarterly.
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)
OR
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:
7. DELIVERY INSTRUCTIONS
*         
Delivery Name:
Delivery Address:
City:
State:
Zip Code:
Phone Number:
Delivery Instructions:
8. OPTIONAL PRODUCTS & SERVICES
Hide-A-Key Lock Box ($39 each) - Exterior lockable safe for quick, secure key access.
Extra Wireless Help Button ($4 each/mo) - Includes pendant, wristband & clip.
Extra 1500' Long Range Wireless Help Button ($4 each/mo) - Includes belt & clothing clip.
Extra Wireless Wall Mounted Help Button ($4 each/mo) - Mounts anywhere in home.
Wireless Activity Assurance Motion Detector ($8 each/mo) - Activity check every 24 hours.
Wireless Smoke Detector ($8 each/mo) - Reports smoke/fire to monitoring center.
Wireless Carbon Monoxide Detector ($8 each/mo) - Reports CO gas to monitoring center.
MedGuardian™ Wireless Monitored Medication Dispenser ($199 + $14/month)
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.
9. ENROLLMENT AGREEMENT APPROVAL AND ACCEPTANCE

Thank you for choosing a LifeGuardianPro™ Medical Alarm System. I understand that a Subscriber Information Form will be included with the LifeGuardian system and that I agree to complete and return the form for complete activation of my LifeGuardian 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 and equipment to LifeGuardian Technologies, LLC no less than 30 days in advance of the next billing period. Service Agreement term is three (3) months and all pre-paid monitoring service fees are non-refundable. I understand and accept that I have up to seven (7) days from delivery to return my new LifeGuardian system without obligation. A one-time, non-refundable $99 account activation and set-up fee applies to all new orders. There are no other fees or charges. Your monthly rate is guaranteed for as long as you subscribe and will never be Increased.

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