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VidaCare ALERT Set Up - Complete Protection
Complete this form to activate your VidaCare ALERT device
SUBSCRIBER INFORMATION - WHO IS THIS FOR?
Subscriber - First Name
*
Subscriber - Last Name
*
Subscriber - Address
*
Subscriber - City
*
Subscriber - State
*
Subscriber - Postal Code
*
Subscriber - Country
*
Subscriber - Date of Birth
*
Subscriber - Contact Phone
*
Subscriber - Language
*
Subscriber - Language
English
Spanish
WHO TO CONTACT REGARDING SERVICE
Service - First Name
*
Service - Last Name
*
Service - Relationship
*
Service - Cell Phone
*
Work Phone
EMERGENCY NUMBERS (NOT 911)
Police
*
Fire
*
Ambulance
RESPONDER 1
R1 - First Name
*
R1 - Last Name
*
R1 - Relationship
*
R1 - Cell Phone
*
R1 - Work Phone
R1 - Does the person have keys to the home
*
R1 - Does the person have keys to the home
A
Yes
B
No
RESPONDER 2
R2 - First Name
R2 - Last Name
R2 - Relationship
R2 - Cell Phone
R2 - Work Phone
R2 - Does the person have keys to the home?
*
R2 - Does the person have keys to the home?
A
Yes
B
No
RESPONDER 3
R3 - First Name
R3 - Last Name
R3 - Relationship
R3 -Cell Phone
R3 - Work Phone
R3 - Does the person have keys to the home?
*
R3 - Does the person have keys to the home?
A
Yes
B
No
HIDDEN KEY LOCATION
CROSS STREETS / NEAREST SERVICE LOCATION
BILLING & PAYOR INFORMATION
Bill to - First Name
*
Bill to - Last Name
*
Bill to - Address
*
Bill to - City
*
Bill to - State
*
Bill to - Postal Code
*
Bill to - Email
*
PHYSICIAN
Physician - Name
Physician - Phone
ALLERGIES
PHYSICAL LIMITATIONS / MEDICAL CONDITIONS
Submit