Order Lifeline

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Please complete the form below and send it to United Lifeline, and one of our representatives will contact you promptly. Below the form, you may also inquire via our website for more information. During a personal visit, we can determine the best location for the Lifeline unit, explain how it works and answer any questions so our new subscriber is comfortable using it in an emergency. Because there is no long-term contract to sign, you can discontinue service at any time. But we know you will be pleased with our service – we’ve made a real difference for more than 10,000 subscribers and their loved ones since 1983, and we can for you, too.

United Lifeline
P.O. Box 411
Woodbury, NY, 11791
Voice: 800-345-4571
Voice: 516-364-3401
Voice: 631-543-3546
Fax: 516-364-3404
unitedlifeline.com

Patient Info

Bill To

First Name*
Last Name*
Address 1*
Address 2*
Cross Street*
Home Phone*
Mobile Phone*
Language*
Date of Birth*
Gender*
Medical Condition*
Drug Allergies*

Shipping

Full Name
Address 1
Address 2
City
State
Zip Code
Day Phone
Evening Phone
Email*
How'd you hear about us?
Is this for you?
yesno
If not, for whom?

Emergency Contacts

Name
Relationship
Home Ph.
Work Ph.
Mobile Ph.
Keys
yesno
Name
Relationship
Home Ph.
Work Ph.
Mobile Ph.
Keys
yesno
Name
Relationship
Home Ph.
Work Ph.
Mobile Ph.
Keys
yesno

If you will be using a private ambulance company:

Ambulance Name
Ambulance No.
Primary Physician Name
Preferred Hospital
Phone No.
Referred by: