ONLINE ORDER FORM

Direct Alert, providing independence, security and peace of Direct Alert, providing independence.

Complete the form below OR print and fax it to 1-877-732-9911
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Personal information
Title
 * First name
* Last name
 * Address
* City
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* Postal code
 * Country
* Date of birth
 
Contact Informations
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* Primary phone number
Your plan
 Purchase: $299.95tx + only $17.95 for monthly monitoring, 24 hours/day
 Rental: $39.95tx per month, equipment and monthly monitoring, 24hours/day included. (3 months minimum)

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Canada

Providing independence, security and peace of mind to Canadians nationwide