Home Technology Solutions, Inc.
1-316-265-1700
contact@homets.org
149 S. Ridge Rd. Wichita, KS

Fields denoted with * are required



Date*


Lifeline Service For*



Gender*
MaleFemale

Phone Number*


Email Address*



Should Home Technology Solutions staff contact the person above for further information and establish an installation time, OR, should someone else be contacted to provide the remainder of the information necessary for the Lifeline installation and set the time for installation? Installations can be set from 8:30 am to 4 pm Monday through Friday.*
YesNo



Contact Person



Relationship to the person receiving the Lifeline service



Phone number to be used for information completion




The information to complete the installation of service for your family or friend is shown on the PDF form which, if you prefer, can be printed, completed, and faxed to our office at 316-682-0624. Otherwise we will take the information in this e-mail, contact the appropriate people to complete the installation process as you direct.


Your inquiry will be acknowledged via the e-mail this form was sent from. If you have further questions or need assistance, please contact our office at 316-265-1700 from 8 am to 5 pm Monday-Thursday, and on Friday’s from 8 am to 4 pm.


We look forward to providing you and your family and friends “Peace of Mind” through the Lifeline System.



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