Senior Safety's Secure Order Form

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ProratedMonth (if no prorate then blank)
TotalCharge
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OrderDate (I think this one is already being passed)
LastMonthOnCycle (if quarterly and is August through October, then October 2011) (MM/YYYY)

American
Senior Safety Agency

Order Online or Call Now
1-888-473-2800

Rated the Best Medical Alert System Nationwide

Pick Your Plan
User Info
Shipping
Billing
Review

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2. Billing Information

Day:

Month:

Year:

Order Summary

Monitoring Plan

Shipping

Priority Mail:Free

Total:$0.00

Need Help?

Call Us At
1-888-473-2800
or

Click Here to Chat With Us

Who is the person ordering? (client)

First Name:

Last Name:

Street Address:

City:

State:

ZIP:

Phone Number:

As a courtesy to you, we can send your paperwork for electronic signature so that your
medical alarm will be activated when you receive it. All we need is you email below…

Email:

Who will be using this system? (user)

Same as Person Ordering

First Name:

Last Name:

Date of Birth:

There will be two people using this system

First Name 2:

Last Name 2:

Date of Birth:

Street Address:

City:

State:

ZIP:

Home Telephone:

Cross Street:

County:

Lockbox or Key Location:

Phone Information for the Home

This information is very important. It helps us program your medical alert
system correctly so that it works properly with your home telephone.

What type of internet do you have in the home?

Dial-up
Cable
DSL
None

Is your home phone service through a Cable or DSL Package?

Yes
No

Is your home telephone through a cell number?

Yes
No

What is the name of the company that provides your home phone service?

Please Note: Having a home telephone service is required to order our
basic or advanced system. If your home telephone is through Verizon Home
Connect or AT&T Wireless Home you must order an advanced system.
Our basic system is not compatible with these services.

Emergency Contacts - save time and enter contacts now

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3. Shipping

Day:

Month:

Year:

Order Summary

Monitoring Plan

Shipping

Priority Mail:Free

Total:$0.00

Need Help?

Call Us At
1-888-473-2800
or

Click Here to Chat With Us

Where should we ship your system?

Same as Person Ordering
Same as User Address

First Name:

Last Name:

Address:

City:

State:

ZIP:

Phone Number:

Priority Mail Shipping
Arrives in 2-3 Business Days

Free

Saturday Delivery

$55.00

Overnight Shipping

$45.00

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4. Billing

Day:

Month:

Year:

Order Summary

Monitoring Plan

Shipping

Priority Mail:Free

Total:$0.00

Need Help?

Call Us At
1-888-473-2800
or

Click Here to Chat With Us

Who is paying?

Same as Person Ordering
Same as User Address
Same as Shipping Address

First Name:

Last Name:

Address:

City:

State:

ZIP:

Phone Number:

Choose your payment method:

Credit or Debit Card

Card type	Card number	Expiration date

Electronic Check
same as mailing us a check except that we will be able to ship your system immediately

Routing Number:

Account Number:

Name of Bank:

Mail a Check
we will wait to ship your system until we receive your payment

Make Check Payable to:
Get Help Now, Inc.
2 Catamaran Street Suite #2
Marina del Rey, CA 90292

Future Billing

Same as above
Change future billing information

Same as Person Ordering
Same as User Address
Same as Shipping Address

First Name:

Last Name:

Address:

City:

State:

ZIP:

Phone Number:

Choose your future billing method:

Credit or Debit Card

We will call to get this information and set up the future bills to autodraft on your card.

Electronic Check
same as mailing us a check except that we will be able to ship your system immediately

Routing Number:

Account Number:

Name of Bank:

Send Invoices to Address Above

Send Invoices to Email

Hello , please review your order

Billing:

,
Phone:
Change

Shipping:

,
Phone:
Change

Other Options:

Extra Lockbox: $.00

() Extra Necklace: $.00

Overnight Shipping: $45.00

Saturday Shipping: $55.00

Change

Payment Plan:

Period:
Cost:

Free Gift:

Change

Payment Method:

Number:
Expires: /

Change

Order Summary

Monitoring Plan

Shipping

Priority Mail:Free

Total:$0.00

Your Questions or Comments:

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