Admitting Clinician Information

Clinician Name (*required)
Clinician Phone
Agency (*required)
Clinician E-mail


Patient Contact Information

Patient Name (*required)
Patient resides in:
Own home, aloneOwn home, with 24-hour careAssisted livingIndependent living
Patient Phone (*required)
Address 1
Address 2


Additional Patient Information

Does the patient currently have a medical alarm?
Does the patient suffer from one or more of the following diseases or conditions? Please check all that apply.
CHFCOPDDiabetesAnginaDyspneaTIA/CVASyncopal Episodes
Has the patient recently fallen, at risk for falls/ or have balance/gait issues?
Does the patient use an assistive device to ambulate?
Is the patient cognitively/functionally able to operate a medical alarm? YesNoCould the patient benefit from our Telehealth Monitoring System for checking weight, blood pressure, and oxygen saturation measurements? YesNo
Is the patient cognitively/functionally able to operate the Telehealth monitoring equipment? YesNo



Proceed with Medical Alarm installation?
Yes, Landline SerivceYes, Cellular ServiceNo
Proceed with Telehealth installation?

I authorize Alert Response, LLC to provide a medical alarm to me on behalf of the agency named above the next 30-60 days at no charge. I understand that after the initial period I will be given the option to continue service privately at a rate of $37.00 ($47.00 for cellular) per month. I authorize the agency to release any necessary medical information to Alert Response in order to facilitate care. I also authorize Alert Response to release any information that may affect my care to the agency and/or my physician.