Annual Medical Alert Service Order Form

Select Your Button & Optional Accessories
Choose the style of personal help button that you prefer. The first button is included with your order.
Select the lockbox option for a secure place to keep a key to allow emergency responders to enter your residence in an emergency.
Name of person completing this form?*
First Last
How did you hear about FamilyCare?*
Choose Your Personal Help Button
Select Pendant or Wristband (Included with service)*
- Pendant
- Wristband
Choose Your FREE Gift!
Select Weekend Special Offer:
- (2) FREE Months (Special)
- (1) FREE Lockbox
4-Digit Secret Code
If you chose a lockbox as your free gift, please enter a four digit secret number that will open your lockbox. The number will only be given to 911 when responding for an emergency.

Client Details
On this page you first select which style of personal help button you want, this button is included with your service. Next, enter the name, address and county of residence for the person using the medical alarm service.
First Name*
Last Name*
Sex*
- Male
- Female
Birth Date
Street Address*
Street Address Address Line 2 City State ZIP Code
County/Township*

Add Your Spouse
If your spouse lives in the same residence and will also be using the medical alarm service, you can add them here. Select he button style you would like to purchase for them and complete the spouse details on this page.
If there is no second person, select No additional person in the help button selection field below.
Choose a personal help button for spouse (Included with service)
- Pendant
- Wristband
- No additional person will be using service.
First Name
Last Name
Sex
- Male
- Female
Birth Date
MM
DD
YYYY

Phone Information
Provide details about the phone service at the residence where the service will be used. All medical alarms are designed to work best on traditional phone lines. If your phone service is provided by a VOIP, DSL, or other non-traditional phone provider the medical alarm may not work as expected in all situations.
Phone Number (Home)
Name of home phone service provider.
Type of phone service in the residence.
- DSL (DSL Filter Required)
- Cable
- Standard Landline
- Not Sure
DSL Filter (*Required for use with DSL phone service)
- Yes, I need a DSL filter ($14.95 One-Time Charge)
A DSL Filter is required to use any medical alarm system on a DSL phone line. You can use your own filter if provided by your phone company, or you can purchase one now with today's order.

Special Instructions for Emergency Responders
Please include any special instructions or details for the Family Care emergency operator and emergency responders. i.e. How can responders get into the house, special directions or landmarks, is there a dog in the home. Only provide important details and keep as short as possible.
Special Instructions for Responders

Select Your Button & Optional Accessories