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Customer Information Guide

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Name _____________________________________________________

Street, / Apt.# _______________________________________________

City _________________________  State _______  Zip ______________

Bill to  (if different than above)

Name _____________________________________________________

Street, / Apt.# _______________________________________________

City _________________________  State _______  Zip ______________

Call List  (in order of preference)
Name, Relation, Phone, and alternate Phone (cell, pager, etc.)
1. ___________________________________________________________________
2. ___________________________________________________________________
3. ___________________________________________________________________
4. ___________________________________________________________________
5. ___________________________________________________________________
6. ___________________________________________________________________

Doctors

Name __________________________________________________________

Office Phone Number ______________________________________________

Emergency Phone Number __________________________________________

Physical History (ex. Heart condition, knee replacement, etc.):

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Medications

____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Allergic Reactions

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

___________________________________________________________________

Local Emergency Phone Numbers

1. Ambulance _______________________________

2. EMS ____________________________________

3. Fire _____________________________________

4. Police ___________________________________

Hospital Preference (with phone numbers)

1. ________________________________________________________________

2. ________________________________________________________________

3. ________________________________________________________________

I, _________________________ , acknowledge that the above information is correct to the best of my knowledge at this time.
___________________ ______________ date

*The above information can be changed at any time simply by calling customer service and giving your account number. There is no charge for changes.

Call us at 1-800-353-1704

Mailing address:
Alarm Technology Solutions, Inc.
P.O. Box 1393
201 Fern Forrest Ct.
Fort Mill, SC. 29715

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