Electronic Caregiver

THE ELECTRONIC CAREGIVER ORDER FORM

You can get protected today by submitting the form below. One of our Customer Service Representatives will call you to complete your order. They will schedule delivery of your Medical Alert System at that time.

In order to protect you, we do not collect any personal medical history or billing information over the internet. We value your privacy.

Your new Electronic Caregiver Medical Alert System will be delivered right to your door, and can be set up in seconds. We include simple step-by-step instructions, and toll free, 24/7 technical support.

LSM51737

Customer's Full Name

Customer Phone

In Care Of (Full Name )

Email *

Confirm Email

Address

Address Line 1

Address Line 2

City

State

Zip Code

Newsletter

Yes - I would like to receive electronic newsletters and promotions with tips about health or caregiving and maintaining independence
No - I do not want newsletters at this time.

* Rquired

I understand and agree that by submitting this web form I am requesting to begin protection through The Electronic Caregiver's products and services. I authorize The Electronic Caregiver to contact me by phone / email / mail.