Order a Vital-Link Personal Emergency Alert System
Please complete the form below to order A Vital Link Personal Medical Alert System service and equipment. Please provide as much information as possible, as this will help us serve you better. On the next page, you will have a chance to review your information.
Personal Medical Alert Service and Button Type
Service Terms
We are proud to offer service without a long-term contract.
Transmitter Type
Necklace (Pendant)    Bracelet (Wristband)
Please choose the type of transmitter device you would like to receive.
Would You Like a Lockbox?
I would like to order a lockbox for a one time fee of $20. (FREE: with web order)
I would not like to order a lockbox at this time.
Lock boxes are used to store a key outside of your house. In case of an emergency we will provide emergency medical services with the combination to your lockbox allowing them access to your home.
Client Information and History
Client Address
Address:
Apartment/Suite:
Complex:
City:
State:
Zip Code:
First Name:
Last Name:
Date of Birth:
Language:
Home Phone:
Rotary    Touchtone
What kind of phone does the
client have?
Yes    No
Does the client have to dial a 9 to
make a call?
DSL    VOIP    Both    Neither
Does the client also have:
eMail:
Client Medical History
Drug Allergies:
Medical Issues:
Primary Phyician:
Primary Physician Phone Number:
Primary Hospital:
Primary Hospital Phone Number:
Secondary Physician:
Secondary Physican Phone Number:
Secondary Hospital:
Secondary Hospital Phone Number:
Emergency Response Information
Response Protocol
Call EMS first then responders    Call the responders first then EMS
How should we respond in case of an emergency?
First and Second Responder Contact Information
Second Responder Name:
Relationship:
Home Number:
Work Number:
Mobile Number:
Alternate Number:
First Responder Name:
Relationship:
Home Number:
Work Number:
Mobile Number:
Alternate Number:
Third and Fourth Responder Contact Information
Fourth Responder Name:
Relationship:
Home Number:
Work Number:
Mobile Number:
Alternate Number:
Third Responder Name:
Relationship:
Home Number:
Work Number:
Mobile Number:
Alternate Number:
Ordering Information
If the person placing the order is the client, please check this box.
Person placing the order
Complex:
City:
State:
Zip Code:
First Name:
Last Name:
Home Phone:
eMail:
Address:
Apartment/Suite:
Shipping Method
What is your preferred method of shipment?
Ship To Information
What is your preferred destination of shipment?
If the shipping address is the same as the client, please check this box.
Specific Ship To Address
Complex:
City:
State:
Zip Code:
First Name:
Last Name:
Home Phone:
eMail:
Address:
Apartment/Suite:
Billing Information
If the billing address is the same as the client, please check this box.
Billing Address
Complex:
City:
State:
Zip Code:
First Name:
Last Name:
Home Phone:
eMail:
Address:
Apartment/Suite:
Credit Card Information
Card Type:
Expiration Date:
Card Number:
Security Code: