Medical Alert Plus - “Live a safe independent life in your own home with a medical emergency response system”

Client Information
You must supply us with accurate information. This must be filled out when placing your order as well as any time there is a change to the information.

Who will be the User of the medical alarm?
First Name:
Last Name:
Cross Streets:
Complex Name:
Address:
City:
State:
Zip Code:
Phone Number:
Email:
Date of Birth
Hearing and Vision
How is the client's hearing?
How is the client's voice?
Information About The Client's Home
Approximated Sq. footage of home?
How many floors are in the home?
Phone and Internet Information
What type of dial tone does the Client have?
Do you have to dial 9 to dial out?	Yes No
INTERNET PHONE WARNING: Medical Alarm will not work properly when plugged into a cable phone line or when using Internet IP phones.
Does the Client have Internet service?
Response Information
How will the paramedics get into the home?

Critical Medical Information:
Current Medical Conditions:

Required Medications:

Known Allergies:

Special Instructions:

Lockbox (location and combination):

Call List Information:

Contact#1:
Full Name :
Phone Number:
Replationship to Client:
Contact has property key?	Yes No

Contact#2:
Full Name :
Phone Number:
Replationship to Client:
Contact has property key?	Yes No

Contact#3:
Full Name :
Phone Number:
Replationship to Client:
Contact has property key?	Yes No

Contact#4:
Full Name :
Phone Number:
Replationship to Client:
Contact has property key?	Yes No

* During an emergency if we receive no response we notify 911 first.

* YOUR PERMISSION IS ALWAYS GIVEN TO EMERGENCY PERSONNEL TO FORCE ENTRY INTO THE HOME IF NO KEY IS AVAILABLE AT THE TIME OF THE EMERGENCY.