Medical Alert System Enrollment Form

Medical Alert System Enrollment Made Simple

A medical alert system can provide peace of mind for patients and their families, ensuring help is always available at the press of a button. This Medical Alert System Enrollment Form template from Paperform streamlines the registration process, capturing everything you need to get patients set up with monitoring services quickly and safely.

Whether you're a home healthcare provider, senior care facility, or medical alert service company, this form collects essential patient information including fall history, chronic conditions, emergency contacts, preferred monitoring service level, and monthly fee authorization—all in one professional, easy-to-complete form.

Why use Paperform for medical alert enrollment?

This template is designed specifically for healthcare providers and medical monitoring services who need to:

• Capture detailed medical history including fall risk factors and chronic conditions
• Document multiple emergency contacts with clear priority levels
• Offer tiered service options with transparent pricing
• Collect payment authorization securely within the same form
• Maintain professional, HIPAA-aware workflows (note: while Paperform is SOC 2 Type II compliant, it is not HIPAA compliant—consult your compliance team for PHI handling)

The form includes conditional logic to ask relevant follow-up questions based on fall history and medical conditions, ensuring you gather the right information without overwhelming patients with unnecessary questions.

Streamline enrollment with automation

Once a patient submits their enrollment, you can use Stepper (stepper.io) to automate your onboarding workflow: send welcome emails, create patient records in your CRM or patient management system, notify your monitoring team, and trigger billing processes—all automatically, with no manual data entry.

You can also integrate with payment processors like Stripe to handle recurring monthly fees, or use Papersign (papersign.com) to send service agreements for electronic signature, keeping all documentation connected to the original enrollment form.

Trusted by healthcare providers

With SOC 2 Type II compliance, secure data handling, and flexible integrations, Paperform helps healthcare and senior care organizations deliver better patient experiences while maintaining professional standards. This template can be customized with your branding, adjusted for different service tiers, and embedded directly into your website for seamless enrollment.

Start enrolling patients in your medical alert monitoring service today with this comprehensive, ready-to-use template.