Activate a Device - Solutions for your Independence Fall Detection Medical Alert Devices for Seniors

*All Devices Must Be Activated By Home & Wellness Before They Can Be Used.
Please Fill Out and Submit the Information Below to Get Your Device Activated.
Our Friendly Staff Will Let You Know That They Are Working on the Activation and Will Let You Know When Your Device is Ready to Use.

First Name

Last Name

Email Address

Customer Phone

Device IMEI Number

Street Address

Street Address Line 2

City

State

Zip Code

Lockbox Information (if Applicable)

Optional Device Insurance, $5/Month

Responder Information

1. First Name

Last Name

Relation

Phone

Type of Phone

2. First Name

Last Name

Relation

Phone

Type of Phone

3. First Name

Last Name

Relation

Phone

Type of Phone

4. First Name

Last Name

Relation

Phone

Type of Phone

5. First Name

Last Name

Relation

Phone

Type of Phone

Medical History & Hospital Information

Preferred Hospital

Medical History (If Applicable)

Payment information

Name on Card

Billing Street

State

Zip Code

Credit Card Number

Expiration Month

Expiration Year

Sec.code

Device Terms and Conditions

By clicking the send button below, you agree to all Device Terms and Conditions in the link above. Typing your signature legally counts as a signature for this contract and instructs Home and Wellness to activate a device for yourself or the person you are caring for listed above on this page.

I agree to all Terms and Conditions

NOTE: Please check your provided email address for updates on activation status
NOTE: Activations submitted after hours will be started as soon as possible, but in some cases may not be completed until the following business day.

Signature (Your Full, Legal Name)

*All Devices Must Be Activated By Home & Wellness Before They Can Be Used. Please Fill Out and Submit the Information Below to Get Your Device Activated. Our Friendly Staff Will Let You Know That They Are Working on the Activation and Will Let You Know When Your Device is Ready to Use.

Responder Information

Medical History & Hospital Information

Payment information

USEFUL LINKS

*All Devices Must Be Activated By Home & Wellness Before They Can Be Used.
Please Fill Out and Submit the Information Below to Get Your Device Activated.
Our Friendly Staff Will Let You Know That They Are Working on the Activation and Will Let You Know When Your Device is Ready to Use.