Medical Alarm Service Subscriber and Product Order Form

AGB Lifesaver Medical Alarms

19 Marlboro Street
Newburyport, MA 01950

877-718-7377(PERS)
9:00 am – 5:00 pm EST

Our Monitoring Center is Open 24-hours a Day.

Please complete as much of this form as possible, if there are questions regarding how to best complete this information please call our toll free number: 877-718-7377.

The contact and medical information is only for Medical Alarm Service orders. At a minimum, we require at least one responder. If there is not a friend or relative that can act as a responder, emergency medical service (EMS) should be listed as the first responder.

We also ask that responders have the ability to arrive at the subscribers’ home within 10 minutes of contact from our monitoring center and have access (keys) to the subscriber’s home.

Billing Information

Please complete the following billing information fields if you are only purchasing a Gift Certificate, Lock Box or Custom Emergency Medical ID Tag. Also, please complete the following billing information fields if you are purchasing Medical Alarm Service or Medication Reminder Service for a loved one.

Send bill to::

First Name:

Last Name:

Address:

City:

State:

Zip Code:

Phone:

Subscriber Information

This is who will be using the Medical Alarm Service products

First Name:

Last Name:

Street Address:

Home Phone:

Cell Phone:

Apartment Number:

Cross Street:

City:

State:

Zip Code:

Email:

Date of Birth:

Primary Language:

Responder Information

List in order of closest responder to subscriber, EMS may be used if Subscriber does not have friends, relatives, or neighbors who can respond quickly.

We will add the contact information for your local EMS/Fire/Police, who will be contacted after the listed responders or will be contacted first if the client indicates an immediate need for emergency service after we receive a medical alarm.

First Responder

First Name:

Last Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Does responder have key?:

Second Responder (click arrow to open)

First Name:

Last Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Does responder have key?:

Third Responder (click arrow to open)

First Name:

Last Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Does responder have key?:

Subscriber Medical Information

Hospital of Choice:

Primary Physician Name:

Primary Physician Phone:

List of subscribers medical conditions:

List of subscribers allergies (drug, food, etc.):

List subscribers medications:

Other Information you would like us to know, such as hidden key location:

Next of Kin or who should be notified if subscriber is transported to the hospital

1) Next of Kin

First Name:

Last Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

2) Next of Kin (click arrow to open)

First Name:

Last Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

3) Next of Kin (click arrow to open)

First Name:

Last Name:

Relationship:

Home Phone:

Cell Phone:

Work Phone:

Person Completing Form

Full Name:

Phone:

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AGB Lifesaver Medical Alarms, 19 Marlboro Street, Newburyport, MA 01950
info@agbmedalarms.com | 877-718-7377 (PERS)