Your personal connection to people who care...

While people choose Lifeline for a number of reasons, they remain subscribers largely because of the caring response they get from Lifeline Monitors every time they push their help button.

Lifeline takes the time to learn all about you. So when you push your help button, the highly trained Lifeline Monitor who answers your call knows your special needs and interests before you say a word. Your health and well-being is our only concern and we're always there when you need us. There is a low installation fee of $37.50 and a monthly fee $37.50.

Join those who are living independently in their homes thanks to Lifeline, a truly personal, caring connection. Why wait? Just fill in the form below and submit. Fields marked with ** are required fields. You'll hear back soon from our Lifeline representative. Thank you!

Today's Date: **

Your Information

First Name: **
Last Name: **
Relationship to Patient: **
Daytime Phone Number: **
E-Mail: **

Patient Information

Patient First Name:
Patient Last Name:
Patient Phone Number:
Street Address:
City:
State:
Zip Code:
County:
Date of Birth: (mm/dd/yy)

Responder Information (family, friends, neighbors who can check on you)

Responder #1
Name:		Relationship:
Home Phone:		Work Phone:
Cell Phone:		Pager:
Responder #2
Name:		Relationship:
Home Phone:		Work Phone:
Cell Phone:		Pager:
Responder #3
Name:		Relationship:
Home Phone:		Work Phone:
Cell Phone:		Pager:
Responder #4
Name:		Relationship:
Home Phone:		Work Phone:
Cell Phone:		Pager:

Emergency Responder Contacts:

Police Phone Number:		Ambulance Phone Number:
Fire Phone Number:
Hospital of Preference:
Physician:		Physician Phone Number:
Directions: