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Canadian Alarm Services™ sells, installs and services residential and commercial security systems and provides ULC listed monitoring.

Medical alarm order form

All fields marked with a * are requried.

Personal Information - About the Customer

First Name:

*

Last Name:

*

Date of Birth:

/ / (Month/Day/Year) *

Address:

*

City:

*

Province:

*

Postal Code:

*

Primary Phone Number:

*

Alternative Phone Number:

Email:

*

Billing Information

Is the billing address the same as the customer's address? Yes No *

Credit card information

The 3-month deposit for the Can-life system and subsequent monthly monitoring payment will be charged to your Credit Card. We'll take your credit card information after you've placed the order using this form.

General Site Information

Is there high speed Internet at customer's address?

Yes No *

If yes, name provider here:

Is there a spare key to enter the residence?

Yes No *

If yes, describe location:

Do you have VOIP (Voice over IP phone service)?

Yes No *

Emergency Contacts

Our standard at Can-life is to have at least three contacts in the system. In the event of an emergency, we will contact these people in the order in which they appear to assist. You may add, delete or update contacts by calling 1-877-554-9407 after activation.

Priority

Contact Name

Relationship

Home Phone

Alternate Contact No.

1 *

2 *

3 *

Dispatch Instructions

Your dispatch instructions may be updated or changed at anytime by contacting Customer Service at 1-877-554-9407.

In the event of an emergency, Can-life will:

Follow the standard protocol for Emergency Response

 

     Please note these additional dispatch instructions on the account:

     



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Canadian Alarm Services™ 2018