New LifeGuardian Subscriber Enrollment Form

Sign-up Online Here and Your LifeGuardian Ships Same 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.

For fastest sign-up, simply complete this order form and you're order will be submitted immediately. If you prefer, click here to print out and FAX or Email your New Subscriber Enrollment Form.

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)
Who Is Your Long Distance Company?
How Did You Hear About Us?
LifeGuardian Representative:
Senior Super Saver Special:
2. PROGRAM SELECTED (Choose One)*
LifeGuardian Service Plans
Purchase / Annual Plan. Purchase for $199. Monitoring is $24/mo - paid yearly.
Purchase / Quarterly Plan. Purchase for $199. Service is $29/mo - paid quarterly.
Purchase / Monthly Plan. Purchase for $199. Monitoring is $34/mo - paid monthly.
Rental / Quarterly Plan. Rent a LifeGuardian System for only $44/mo - paid quarterly.
Rental / Annual Plan. Rent a LifeGuardian System for only $39/mo - paid yearly.
3. EQUIPMENT PURCHASE & ACCOUNT ACTIVATION
A credit card is required for rental or equipment purchase & 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 (Save $2/month!)
Bank Name:
Account Number:
Routing Number:
  (Please FAX a voided check to 800-209-3813)
6. DELIVERY INSTRUCTIONS
*         
Delivery Name:
Delivery Address:
City:
State:
Zip Code:
Phone Number:
Delivery Instructions:
7. RECOMMENDED PRODUCTS & SERVICES
Key Safe Lock Box ($4 each/month) - Exterior lockable safe for quick, secure key access.
Extra 400' Wireless Help Button ($4 each/month) - Includes pendant, wristband & clip.
Extra 1500' Wireless Help Button ($4 each/month) - Includes belt/clothing 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 presence of CO2 to monitoring center.
24 Hour Activity Assurance Monitor ($8 each/month) - Includes wireless motion detector..
MedGuardian Wireless Monitored Automatic Pill 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.
8. ENROLLMENT AGREEMENT

Thank you for choosing a LifeGuardian™ 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 monthly, quarterly or annual service plan selected above will renew automatically until I cancel this authorization by delivering written notice 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 seven days from delivery to return my new LifeGuardian system. All new accounts are subject to a one-time, non-refundable $99 Activation Fee. There are no other usage fees or charges. Your monthly rate is guaranteed for as long as you subscribe and will never be Increased. Cancel without penalty fees or early termination fees at any time.

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