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Online orders are only available with self installation. If you would like Vital Link to install your system in the Bay Area please call our office at 510-338-3466. The monthly plan is subject to an $9 shipping fee.
   
 

Choose a Product
 
Two-Way Voice Unit Two-Way Voice Unit


($27 a month)
 
Automated Medication Dispenser Medication Dispenser

($28 a month)
 
  Vital Link System plus Medication Dispenser
 
Cord-Mate Cord-Mate
Cord-Mate: $25 month
 
 

Please check off any additional products you would like
Lockbox Lockbox ($35 + tax for CA residents)
Additional Pendant Additional Pendant ($35 + tax for CA residents)
Would you prefer a neck pendant or a wrist button? Neck Pendant Wrist Button
  If you are not the client, who is placing this order?
  I am the client
Name:
Address:
Address line 2:
City:
State:
Zip Code:
(Area Code) Phone Number ( )
  Client Information
Date of birth:
Name of client:
Address:
Address line 2:
City:
State:
Zip Code:
(Area Code) Phone Number: ( )
Email Address:
Cross Street:
Do you have internet access?
If yes, who is your internet service provider? (Comcast, AT&T, etc.)
  List of Responders
A responder should be somebody that lives roughly 10-15 minutes away such as a neighbor or family member. These people may be called to assist in a non-emergency or meet paramedics at the clients home if there is an emergency. If somebody does not live close by but would like to be notified, scroll down.
Responder 1 Name: Has Key
Responder 1 Phone Number: ( ) Home Work Cell
Responder 1 Phone Number: ( ) Home Work Cell
Responder 2 Name: Has Key
Responder 2 Phone Number: ( ) Home Work Cell
Responder 2 Phone Number: ( ) Home Work Cell
Responder 3 Name: Has Key
Responder 3 Phone Number: ( ) Home Work Cell
Responder 3 Phone Number: ( ) Home Work Cell
  Notify Only List
A person can be notified if they live far away from the client but would like to be called to let them know that the system was activated and what happened.
Notify Only 1 Name:
Notify Only 1 Phone Number: ( ) Home Work Cell
Notify Only 1 Phone Number: ( ) Home Work Cell
Notify Only 2 Name:
Notify Only 2 Phone Number: ( ) Home Work Cell
Notify Only 2 Phone Number: ( ) Home Work Cell
  Medical Info
Your preferred hospital but in the case of an emergency EMS will take you to the closest hospital:
Doctor's Name
Doctor's Phone Number ( )
Medical Conditions:
Allergies:
Remarks/Special Instructions/Key Location/
  Billing Information (If different from client)
Although this is just a month to month agreement, when shipping a unit we do need 3 months of payment up front and if you should cancel before that time, you will receive a refund.

Please complete the payment information forms and fax or email them to us.
Click here for Credit Card Authorization Form
Click here for Direct Payment Authorization Form
Name:
Address:
Address line 2:
City:
State:
Zip Code:
(Area Code) Phone Number: ( )
We like to thank those that refer our company.
How did you hear about us?
**REQUIRED** Submitting this form gives rescue permission to enter my house if no key is available at the time of the emergency.  I also certify that the above monitoring data is correct. I understand any changes to this data must be made in writing to Bay Area Vital-Link, Inc. I further understand that Vital Link's liability is limited and is not obligated to monitor until a signed copy of the system agreement is received. I have reviewed it and agree to the terms and conditions.
   
 

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