Emergency Contact Information0 Comments Customer Information Needed In order to best serve our customer’s needs we require the following information to tailor our response to your desires. Please fill in the information for the person who will be using the equipment. Also we recommend three people whom we can contact in case of emergency. A responder is usually a friend, neighbor, or family member that lives within 20 minutes of the individual and is able to help. A notified person is one who needs to be updated to events that may occur. If you prefer you can call 866.922.8339, 9am to 5pm (CST) to talk to us directly. Customer Name (required) Your Email (required) Your Date of Birth (required) Your Products Responder 1 Name (required) Responder 1 Relationship To Client (required) Contact Type NotifyResponderNotify & Responder Responder 1 Phone Number (required) Responder 2 Name Responder 2 Relationship To Client Contact Type NotifyResponderNotify & Responder Responder 2 Phone Number Responder 3 Name Responder 3 Relationship To Client Contact Type NotifyResponderNotify & Responder Responder 3 Phone Number Below you will see some letters and numbers. Enter these in the box below and click submit before proceeding to the next step.