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Please provide information below:

    Client Info:

    Physical Address (cannot be PO Box):

    Person Ordering Services:

    Which System would you like to order:

    System options you would like to discuss:

    Would you like us to ship it to you or assist with in home set up?

    We offer 3 forms of payment. Monthly to a credit card, monthly through a checking account or annually by check. We will contact you by phone to obtain the payment information.

    Address

    Nodak Medical Alert
    P.O. Box 273
    Rugby, ND 58368

    Phone:

    701-881-0108