Order Form

Order form for the Life Beacon Medical Alert System

Bill to:
Name
First Last
Email
Phone
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Service Address
Name
First Last
Phone
Service Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Order Form
Activation and Programming Fee Regular Pendant
Price: $99.00 Quantity:
Necklace
Price: $14.99 Quantity:
Bracelet
Price: $14.99 Quantity:
Leather watch band
Price: $14.99 Quantity:
Total Fee
$0.00
Monthly Monitoring
A service plan is required with purchase of the device.
Two Year Monitoring Agreement
Price: $29.95 Quantity:
Device Repalcement Protection Monthly
Price: $4.95 Quantity:
Payment Information
I (we) hereby authorize Emergency Response Systems (The Company) to initiate entries to my (our)Credit Card account listed below and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until THE COMPANY is notified by me (us) in writing to cancel it in such time as to afford THE COMPANY and the Credit Card Company a reasonable opportunity to act on it.
Credit Card Number
Expiration Date
SSID
Billing Zip Code
Name on Card
First Last
Signature
By signing above you agree to the terms and conditions found by clicking here.
Date
Emergency Contacts
Contact #1 Name
First Last
Contact #1 Phone
Contact #2 Name
First Last
Contact #2 Phone
Contact #3 Name
First Last
Contact #3 Phone
Contact #4 Name
First Last
Contact #4 Phone

Bill to: