American Medical Alarms - Medical Alert for Seniors American Medical Alarms - Information about Medical Alert Systems for Seniors
American Medical Alarms, Inc.
"Help When You Need It, Peace of Mind All the Time"

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Order a Medical Alert System

Orders received by 4:00pm EST ship the same day.
You can also order by phone by calling (800) 542-0438 Mondays-Fridays 8:30am-7:45pm EST and Saturdays 8:30am-4:45pm EST.

Instructions for Completing this Order Form

To help make this form as easy as possible to complete we have included some instructions and examples beside the form fields to assist you. The form has been broken down into a few pages in order to help simplify the process as well. When you complete a page please click the button at the bottom of the page to continue. If there is more than one button please click the one that best describes what you would like to do next.
Items marked with a * are required.

Placing the Order

Who are you placing this order for? * required

If you are placing this order for someone else, please provide your name and relationship to the person who will be using the system?

Number of Clients

How many people will be using the alarm? * required

There is no additional monthly fee to have a second person on the account.

Name and Date of Birth

Please enter the name of the first person who will be using the alarm below:

* required * required

* required format mm/dd/yyyy Ex. 01/01/1952

Please enter the name of the second person who will be using the alarm below (if applicable).

Ex. 01/01/1971

911 Address Where the Alarm Will Be Located

Please provide the address where the alarm will be used. This should be your 9-1-1 address and can not be a P.O. Box.

* required

* required * required Abbreviation Ex. FL

* required 5 digits only

* required 10 Digit Number Only (Ex. 5555555555). Can not be a cell phone.

Please enter your township/county/parish/borough for rescue (if applicable).

Please enter basic directions to the address where the alarm will be used. If you are not sure of the directions you can leave this field blank and we can get directions from you later. Limited to 150 Characters

Please enter any special instructions below. For example if you were going to hide a key tell us where it is hidden or if there is something we need to know about entering your home. Limited to 150 Characters

Mailing Address

Is the mailing address for the client(s) listed above: *

Please provide the mailing address for the client(s) listed above if different from the 911 Address.

Ex. FL 5 digit zip code

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