Activate your 24h service Fill out the form below and allow 24 hours before testing your equipment. For any questions or concerns, please call 1-877-391-1767. Step 1 of 4 - Product & User Information 25% Product InformationWhich Medical Alert System Did You Purchase?*ClassicFall DetectionTalk-thruCellularMobileUnit Account Number*6 digits located underneath your mobile device, cradle or outside of shipping box ##-####Unit Account Number*6 digits located underneath your machine ##-####User Information(The person who will be using our service)Name* First Last Phone Number*Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906190519041903190219011900Address* Street Address City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Does the user have an email address?YesNoUsers or Caregivers E-mail Address* This field is required to access our CareCoud online platform and to enable monitoring of the mobile device.Users E-mail Address Email Consent DirectAlert can send updates, news and offers to this email address Would you like to fill out medical information such as health conditions, medications taken and doctors information?Yes, I would.No, not at this time.Medical Information(Please check any conditions related to the user) Lungs Kidneys Heart Cancer Diabetes - Type A Diabetes - Type B Arthritis Locomotion Speech Semi-deaf Deaf Epilepsy Alzheimer Blind Semi-blind Other Lung ConditionKidney ConditionHeart ConditionCancer ConditionOther ConditionDoes the user use any of the following? Cane Walker Wheelchair MedicationsAllergiesOther Health InformationPrimary Care PhysicianDoctors NameHospital / ClinicPhone Emergency ContactsWho should we contact in an emergency?*Full NamePhone Number(s)Relationship to user * Specify neighbors, friends or family. ADD UP TO 4 CONTACTS * Our default contact is 911.Emergency Access InformationIs there a spare key to enter the residence?YesNoWhere is the spare key located? Payment Method*I have already paid for my 24h protection planI need to pay for my 24h protection planPayment Terms*$19.95 Monthly (Recurring)$239.40 YearlyDoes not include your local sales tax.Payment Terms*$29.95 Monthly (Recurring)$359.40 Yearly (Recurring)Does not include your local sales tax.Payment Terms*$29.95 Monthly (Recurring)$359.40 Yearly (Recurring)Does not include your local sales tax.Payment Terms*$39.95 Monthly (Recurring)$479.40 Yearly (Recurring)Does not include your local sales tax.Payment Terms*$49.95 Monthly Recurring (Without Fall Detection)$59.95 Monthly Recurring (With Fall Detection)Does not include your local sales tax.Email address for billing & order confirmation* Billing Address*Same as user addressBill to a different addressPayee Name* First Last Billing Address* Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland & LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Credit Card InformationCredit Card Type*Please specify...VisaMastercardCard Holder's Full Name*Card Number*Expiration Date (MM/YY)*Security Code*3 digits located on the back of the card.* I've read and accept the terms & conditions Full name of the person filling out this form*Phone Number** I've read and accept the terms & conditions This iframe contains the logic required to handle Ajax powered Gravity Forms.