ACTiVATION FORM
Enter your information in the form below to activate now or activate by phone by calling 1-877-ALERT 24 (1-877-253-7824) from 8am to 12am eastern standard time.


Unit Account Number
(4 or 7 digit number located on the back of your panel)
First name * Last name
Date of birth
Address * Address2
City Province
Postal code Country
Primary phone number * Secondary phone number
(Primary phone number will be dialed back in an emergency)
Email *
 Coupon Code
High speed internet If Yes, high speed provider
Payment type
 Credit card
 Pre-authorized bank account debit
 Bill me later

 Please send your void check to Direct Alert upon completion of this form. Your check can be sent by any of the following methods:

 Mail: Direct Alert
460 Isabey Street
Montreal, Quebec
H4T 1V3

 Email: Info@directalert.ca

 Fax: 1-877-732-9911
Credit card
Fullname on credit card   (ex: John Smith)
Credit card number  (ex: 4132 XXXX XXXX XXXX)
Credit card expiry date  (ex: 03/09)
Medical information (Please check any conditions related to the following)
Lungs Specify
Kidneys Specify
Heart Specify
Cancer Specify
Diabetes If yes >> Type A Type B
Arthritis Semi-deaf Deaf
Locomotion Epilepsy Alzheimer
Speech impairment Blind Semi-blind
Do you use any of the following ?
Cane Walker Wheelchair
Medications (please specify name of medication and dosage)
Allergies (Please include allergies to medications)
Other specific information pertaining to your state of health
Other relevant information or special instructions
Do you have a spare key to enter your residence?
Yes No

If YES, please specify where the key is located
Primary care physician

First name

Hospital / Clinic

Primary phone number

Ambulance local telephone number

Fire local telephone number

Police local telephone number
If your personal help button is pressed and we are unable to speak to you through the panel’s two way voice who should we contact? (Specify neighbors, friends or family who live or work within 15 minutes of your home)
Emergency contact 1 (optional) Emergency contact 2 (optional)
Full name
 Full name
Phone number(s) Phone number(s)
Relationship to user Relationship to user

Emergency contact 3 (optional)
Emergency contact 4 (optional)
Full name
 Full name
Phone number(s) Phone number(s)
Relationship to user Relationship to user
In the case of an emergency after contacting the police / ambulance / fire department, who should we should contact? (These contacts are friend or family who are unable to assist in a timely manner but need to be notified in an emergency)
Notify contact 1 (optional) Notify contact 2 (optional)
Full name
 Full name
Phone number(s) Phone number(s)
Relationship to user Relationship to user

Notify contact 3 (optional)
Notify contact 4 (optional)
Full name
 Full name
Phone number(s) Phone number(s)
Relationship to user Relationship to user

List of our Partners:

Sears
aine411
Costco