< Medscope ::

Medical Alert Systems
Call Now:   1.800.645.2060

Medical Alert System Order Form

Customer Address

(this is where we will dispatch help during an emergency)
 
Last Name
First Name
Middle Initial
Address 1
Address 2
City
State
Zip Code
Premise phone
Email

Shipping Address

(this is where the equipment will be shipped)
Click here if the shipping address is the same as the customer address above.
 
Last Name
First Name
Middle Initial
Address 1
Address 2
City
State
Zip Code
Shipping phone
Email

The following Emergency Contacts will be notified in the event of an emergency.

Emergency Contact 1 Relationship
Home Phone# Work Phone#
Cellular Phone#
Emergency Contact 2 Relationship
Home Phone# Work Phone#
Cellular Phone#
Emergency Contact 3 Relationship
Home Phone# Work Phone#
Cellular Phone#
Emergency Contact 4 Relationship
Home Phone# Work Phone#
Cellular Phone#

Please fill in the box below if you have been referred by one of our existing customers.
This customer will get a free month of service for referring you!

Referred By
Transmitter Style (please check one): Pendant Wristband
 
Extra Transmitter (optional): Pendant Wristband
Extra transmitters carry a one-time charge of $25.00
 
Lock Box Style (optional): Hanging (door knob) Wall Mount
Lock Boxes carry a one-time charge of $55.00
A monthly monitoring fee of $35.00 will be applied to your credit card.
 
Card Type:
Name on Card:
Card Number:
* Please enter without spaces or dashes
Exp. Date: Month: Year:
I have read and agree to the terms and conditions

Medical-Data Service Login


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Password
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