Referral Program for Individuals

Join Our Program Today

Do you know someone that lives alone, has a medical condition, or needs special assistance that could benefit from a personal emergency response system from Galaxy Medical Alert Systems?

If you refer someone you know to Galaxy Medical Alert Systems, we will give you and the person you refer ONE-MONTH FREE of medical monitoring services. This is merely our way of saying thank you for being a valuable customer and for referring Galaxy Medical Alert Systems personal emergency response systems (PERS).

Get one-month free by referring someone to Galaxy Medical Alert Systems.

Referral Program for Individuals Form

Please fill out the form below to join the Referral Program.

Your Contact Information
Name*
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Cell Phone
Email*
Your Sales Person
First Last
Referral Information
Please fill out the following fields for the person you want us to contact.
Referral Name*
First Last
Referral Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Referral Phone*
Referral Email*
CAPTCHA
11+9=*
(After entering the correct answer in the box above, the Submit button will appear.)
Phone
This field is for validation purposes and should be left unchanged.