Emergency Contact Information

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


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Contact Us

(316) 262-8339 Voice
(866) 922-8339 Toll-Free
3510 W. Central Suite #100
Wichita, KS 67203