Orange County Office on Aging (CF986): Senior Medical Alert Device Application

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Orange County Office on Aging (CF986): Senior Medical Alert Device Application

Thank you for submitting this short application.

Your responses will help determine if you qualify for the Senior Medical Alert Device Program.

The Senior Medical Alert Program includes a 12-month device monitoring service for all participants. Participants may choose to self-pay for continued device monitoring service after 12 months of activation.

Email *

Are you an older adult (60 years or older)? *

Yes

Please provide your first and last name. *

Please provide your date of birth. *

YYYY

Please provide your gender *

Male

Female

Prefer not to say

Please select your primary language *

English

Chinese

Korean

Spanish

Vietnamese

Other:

Please provide your phone number *

Please provide your complete home address including city and zip code *

Please note any medical conditions (including any known allergies) you would like listed on your profile. *

Do you have a pacemaker? *

Yes

Do you need a secured lockbox to store an extra set of house keys? Note: A secured lockbox can be provided upon request so emergency responders can have access to the participant's home in case they are incapacitated.

Yes

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