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Payment Plan
*LifeResponder 24/7 Monitoring Service
Paid Annually | $25.95 / month | Unit Lease Included
Paid Quarterly | $26.95 / month | Unit Lease Included
Paid Monthly | $27.95 / month | Unit Lease Included
Paid Annually| $12.95 / month | Unit Cost $189.95
Paid Quarterly | $13.95 / month | Unit Cost $189.95
Person Placing Order
*First Name
*Last Name
*Address
*City
*State
*Zip Code
E-mail Address
*Phone Number
Additional Contact Number
Person Using System
*Person Using System
Different then person placing order
Same as person placing order
*First Name
*Last Name
*Address
*City
*State
*Zip Code
Cross Streets
*Phone Number
*Ship To
Person Placing Order
Person Using System
Other Address
*Who is this system for?
Mother
Father
Myself
Grandmother
Grandfather
Mother-in-Law
Father-in-Law
Husband
Wife
Aunt
Uncle
Friend
Brother
Sister
Patient
Son
Daughter
Other
Special Instructions
Emergency Contact Information
Police Dept. Name
Police Dept. Phone
Fire Dept. Name
Fire Dept. Phone
Ambulance Name
Ambulance Phone
Preferred Hospital (Cannot Be Guaranteed)
Hospital Phone
*Would you like Emergency Responders called before or after your notification list
Before
After
Household Hideen Key Location/Lockbox Combination #
Notification #1
Relationship
Has Key?
Phone Number
Notification #2
Relationship
Has Key?
Phone Number
Notification #3
Relationship
Has Key?
Phone Number
Notification #4
Relationship
Has Key?
Phone Number
Notification #5
Relationship
Has Key?
Phone Number
Notification #6
Relationship
Has Key?
Phone Number
Notification #7
Relationship
Has Key?
Phone Number
Notification #8
Relationship
Has Key?
Phone Number
Optional Features
Lock box
Yes, I want to receive a Lock box that will hold a key to my house. In case of emergency, it will prevent a forced entry by emergency personnel.
Only $2.99 / month ( 10 cents / day )
Purchase for $39.95
Extra Help Button
Yes, I want to receive an extra help button for another person or myself or keep in another area of my home.
Only $3.49 / month (12 cents / day )
Purchase for $39.95
Monitor Detection
Yes, I want to receive Monitor Detection service. This will notify LifeResponder if no activity is reported in a 24 hour time period.
Only $8.99 / month ( 30 cents / day )
Best Time To Call
*Call Times
Morning
Afternoon
Evening
Comments
How did you hear about us?
Please select the payment method
*Payment Method
Credit Card
Check
*Name on Card
*Credit Card Number
*Expiration Date: Month
01
02
03
04
05
06
07
08
09
10
11
12
*Year
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
*CCV
Security Code
Security Code:
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