Health Alert

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Health Alert

Equipment Update, Exchange or Repair Request

Complete this form to request a repair or exchange or your Health Alert equipment. Please note: You must be a current Health Alert subscriber to use this form.

*Required fields


Client first name*
Please enter your first name.

Client last name*
Please enter your last name.

Service request*
Invalid Input

Person to contact to arrange appointment*
Please enter your first name.

Phone*
Please enter your 10 digit phone number.

  xxx-xxx-xxxx

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

Your phone*
Please enter your 10 digit phone number.

  xxx-xxx-xxxx

Notes:*
Please enter info


Use this area to provide more information to the Health Alert team.