LifeGuardian Subscriber Update Form

Simply and quickly update subscriber information!

Please take a few minutes to complete the Update Subscriber Information Form and your order will be transmitted electronically direct to the LifeGuardian Customer Service office. Updates are generally inputted into the system within one business day.

If you prefer, click here to print out and FAX your Update Subscriber Information Form.

Please Note: * Indicates required field.

1. SUBSCRIBER INFORMATION
LifeGuardian Account Number:
*Subscriber (User) Name:
*Physical Address:
Apartment/Unit #:
Nearest Cross Street:
*City
*State:
*Zip Code:
*Telephone Number: (Please Include Area Code)
Location of Hide-A-Key :
Key Safe Combination:
Property Access Code:
How Did You Hear About Us?
LifeGuardian Representative:
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?
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 Technologies, LLC, 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 Technologies, LLC. 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
Referred By:
Referrer's Phone Number: