Health Alert

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Health Alert

Service Cancellation/Equipment Return Request

Complete this form to discontinue your service. When we receive your request we will send a box in which you can return your Health Alert equipment. The box will include a prepaid label so there will not be a cost to you.

Please note: This request does not cancel or stop billing unless an address is provided for the box to be sent, or the unit is received back in our office.

*Required fields


Client first name*
Please enter the client's first name.

Client last name*
Please enter the client's last name.

Reason for request*
Please enter the reason for your request.

Person to contact to arrange appointment*
Who should we contact to arrange an appointment?

Phone*
Please enter a valid 10-digit phone number.

  xxx-xxx-xxxx

Name of person completing this form*
Please enter your name.

Your phone*
Please enter your 10-digit phone number.

  xxx-xxx-xxxx

Notes
Please enter info


Use this area to provide any notes or special instructions for the Health Alert team.