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Division of Acadian Companies

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Agency Referral Form

AOC Telehealth

Medical Alert Subscriber Registration

* Denotes a required field

Guarantor Information:

First Name:

Last Name:

Email:

Telephone #:

Pay By Credit Card:

I would like to purchase:

	Medical Alert Monitoring $29.95/mo
Lock Boxes: $29.99 (plus tax in TX, LA, MS)
	Mounted (Black)
	Door Model (Black)
	Text Messaging Service $2.99/mo
Shipping

Name on Credit Card

Credit Card Number

Exp Date (mm/yyyy)

/

Billing Address:

Street Address:

City:

State:

Zip:

Parish/County:

Shipping Address: (if different from billing address)

First Name:

Last Name:

Street Address:

City:

State:

Zip:

Subscriber Contact Information:

First Name:

Last Name:

Customer Email:

Telephone #:

Street Address:

City:

State:

Zip:

Directions to Residence:

Nearest Cross Street:

Subscriber General Information:

Date of Birth:

/ /

Weight:

Doctor's name:

Doctor's Telephone #:

Preferred Hospital:

Sex:

Male Female

Medical Problems (ex: heart attack, stroke):

Medications:

Drug Allergies:

Hidden Key Location:

Responder List:

Responder List:

1.

Name

Relation

Phone

Cell

Work

2.

Name

Relation

Phone

Cell

Work

3.

Name

Relation

Phone

Cell

Work

4.

Name

Relation

Phone

Cell

Work

Where did you hear about us?:

General Information:
Acadian Companies | P.O. Box 98000 | Lafayette, LA 70509-8000 | 1.800.259.3333

Deliveries:
300 Hopkins Street | Lafayette, LA 70501

Acadian Ambulance Service | Air Med Services, LLC | Safety Management Systems, LLC | Acadian Monitoring Services | Executive Aircraft Charter Service | National EMS Academy