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. Our equipment installation technician 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 25,000 subscribers and their loved ones since 1983, and we can for you, too.

The Patient Information Form can be filled out and sent to us, for your convenience, if you are ready to schedule an installation appointment. There is no additional cost  for the installation. Please note, the Contact page offers another option for access to further information about our services.

United Lifeline
71 Grove Street
Glenwood Landing, NY 11547

Tel: (800) 345-4571
Tel: 631-LIFELINE
Tel: 516-364-3401

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: