AGB Lifesaver Medical Alarms

Medical Alert Systems and Service that Seniors and Caring Families Can Trust

Medical Alarm Service Subscriber and Product Order Form

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.

Subscriber Information

This is who will be using the Medical Alarm Service products

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
Subscriber Medical Information
Next of Kin or who should be notified if subscriber is transported to the hospital
1) Next of Kin
Person Completing Form
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