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LifeFone EZ Referral

Submit this form to refer your clients and keep them protected and living independently 24/7/365 with LifeFone!

Upon submission, a copy will be sent to the email address you provide below. If you have any questions,
please reach out to a partner care specialist at 1-800-882-2280 x 300 or email us at [email protected].

"*" indicates required fields

Referred by: *
Equipment Recommended:*
Optional Fall Detection*
Help Button Type:
Check option if you choose At Home Landline or At Home Cellular
Subscriber Information: *
Address*
MM slash DD slash YYYY
Emergency Contact: *
Important Notes:

Need help making a referral?
1-800-882-2280 x 300
[email protected]

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