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Pendant Activation Form

Please fill out the information below:

Are you filling this form out for you or someone else?

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Are you filling this form out for you or someone else?

For you

For someone else

Please use the client's legal name here (e.g., Margaret, not Maggie); you can share the name you typically use below!

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Address

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Date of Birth

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Personal Information

Marital Status

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Marital Status

Single

Married

Divorced

Prefer not to say

Gender

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Gender

Male

Female

Please Select those that apply:

Please Select those that apply:

Weapons

Speech Impaired

Has pets

Pets bite

Hearing impaired

Disabled

Child in house

Oxygen

Med list on fridge

Add fall detection ($4.99/month - First month free)

Untitled checkboxes field

Add Pendant Insurance for lost or stolen pendant ($3.99/month - First month free)

None of these apply