Transfer Your LifeGuardian Medical Alarm SystemLifeGuardian 911 Medical Alert Alarm Systems

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 (User) 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. LifeGuardian Service Plans (Choose One)
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. 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:
7. Optional Products & Services
8. Service Agreement Acceptance
*Agreement Acceptance
*Accepted By (Type Name):
*Date Completed:
*Phone Number:
*Email Address