Application for Lifeline Medical Alert Service

First name

Last name

Birthday

Month

Day

Year

Physical Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Mailing Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Type of Phone

Physician Contact Information

Name

Phone Number

Please check if you have a fall risk condition.

Please check if you have a pacemaker.

Emergency Contact Information

Name

Relationship

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone 1

Phone 2

I certify that the information above is true and correct to the best of my knowledge. I understand that I am applying to The Friends Foundation for Lifeline Medical Alert equipment, to be leased by The Friends Foundation on my behalf. I also understand that I must notify The Friends Foundation when the equipment is no longer needed, and that I may be billed $500 if the equipment is not returned in a timely manner.

Signature

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First name

Last name

Birthday

Month

Day

Year

Physical Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Mailing Address

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone

Type of Phone

Physician Contact Information

Name

Phone Number

Please check if you have a fall risk condition.

Please check if you have a pacemaker.

Emergency Contact Information

Name

Relationship

Multi-line address

Country/Region

Address

City

Zip / Postal code

Phone 1

Phone 2

Signature

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