Transfer Your LifeGuardian Medical Alarm System

Please take a few minutes to complete the Transfer Subscriber Information Form and your transfer 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 transfer order form and you're order will be submitted immediately. Don't have all the information right now? Remember... you can simply provide new subscriber name, physical address, phone number and billing 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
LifeGuardian Account Number:
Previous LifeGuardian Subscriber Name:
*New Subscriber (User) Name:
*Physical Address:
Apartment/Unit #:
Nearest Cross Street:
*City
*State:
*Zip Code:
*Telephone Number: (Please Include Area Code)
Email Address:
Location of Hide-A-Key :
Key Safe Combination:
Property Access Code:
2. CRITICAL MEDICAL INFORMATION
Date of Birth:
Blood Type:
Preferred Hospital:
Medical Conditions:
Required Medications:
Known Allergies:
Special Instructions:
3. EMERGENCY CONTACT LIST
Contact #1
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location:
Relationship to Subscriber:
Contact Has a Property Key?
Contact #2
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location:
Relationship To Subscriber:
Contact Has a Property Key?
Contact #3
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location:
Relationship To Subscriber:
Contact Has a Property Key?
Contact #4
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location:
Relationship To Subscriber:
Contact Has a Property Key?
Contact #5
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location:
Relationship To Subscriber:
Contact Has a Property Key?
Contact #6
Full Name:
Full Phone Number: (Please Include Area Code)
Phone Location:
Relationship To Subscriber:
Contact Has a Property Key?
4. PROGRAM SELECTED (Choose One)
LifeGuardian Service Plans
Annual Plan. 24/7 Personal Emergency Monitoring is $24/mo - paid yearly.
Quarterly Plan. 24/7 Personal Emergency Monitoring is $29/mo - paid quarterly.
Monthly Plan. 24/7 Personal Emergency Monitoring is $34/mo - paid monthly.
5. BILLING INSTRUCTIONS
Bill To Subscriber                 Bill To Another (complete below)
Full Name:
Billing Address:
City:
State:
Zip Code:
Phone Number:
Email Address:
6. MONITORING SERVICE PAYMENT METHOD (Choose One)
Credit Card
Name On Card
Card Number:
Expiration Date:
OR
Deduct From Checking/Savings Account
Bank Name:
Account Number:
Routing Number:
8. OPTIONAL PRODUCTS & SERVICES
9. APPROVAL AND ACCEPTANCE
Subscriber, or their legal or authorized legal representative, hereby acknowledges that they have received, read, understand and accept without limitation or exception, the Subscriber Service Agreement Terms and Conditions. I agree that ordering, receipt, activation, testing or use of my System constitutes its acceptance of this Agreement and all future updates to this Agreement, as published by LifeGuardian Healthcare Inc. and it shall be binding and effective upon either execution date below or the delivery date of my System whichever occurs first. I authorize LifeGuardian Healthcare, Inc. or its assignee, Monitoring Services, to initiate and commence ongoing electronic debits from my credit card or bank account for all amounts I owe under this agreement as directed above. I understand the monthly, quarterly or annual service plan selected above will renew automatically until I cancel this authorization through written notice 30 days in advance of the next billing period. I have been given the opportunity to read and make a copy this agreement prior to activating my LifeGuardian account.
*Agreement Acceptance
*Accepted By (Type Name):
*Date Completed:
*Phone Number:
*Email Address