8/3/2019 Medic Alert Short Brochure

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P e r s o n a l I n f o r m a t i o n(Please print clearly)

Previous/current MedicAlert member? qYes qNo

If yes, enter member number

Last four digits of SSN

qDr. qMr. qMrs. qMs. qMiss

First name Middle name/initial

Last name Sufx

Mailing address

City State Zip

Phone

Gender qM qF

Date of birth (MM/DD/YYYY)

E-mail address

E m e r g e n c y C o n t a c t s

*Primary contact to notify/relationship

Primary contacts phone Primary contacts second phone

*Second contact to notify/relationship

Secondary contacts phone Secondary contacts second phone

Primary physician/specialty

Phone

Health insurer

Group plan number Insurer member number

*Only contacts listed can update members record.

( )

( )

( )

( )

( )

( )

M e d i c a l C o n d i t i o n s / A l l e r g ie s(Please print clearly)

If there are any known medical conditions or allergies, please list below.

q No known medical conditions

*If you need to include more medical conditions, allergies or medications,please attach a separate sheet of paper or call us with your order.

M e d i c a t i o n s(Please print clearly)*List all medications and dosages, including inhalers.

Medication Prescribed Dosage

E n r o l l m e n t

Enrollment in the MedicAlert Advantage Service includes creationand management of your MedicAlert Emergency Medical Information

Record (EMIRSM), a MedicAlert Wallet Card with your emergencyinformation imprinted, secure online access to your MedicAlert

Emergency Medical Record, and the MedicAlert Emergency ResponseService on call 24 hours a day, seven days a week to help you at any

time. Your annual membership renewal fee will be $35.

Enrollment fee $39.95

Select your product(s): Price

Price

Charitable contribution*

Shipping and handling $4.95

FedEx shipping additional $10(required with watch orders)

TOTAL

Method of paymentqCheck q Money OrderqMasterCard q Visa q Discover q AMEXNo other cards accepted. No CODs. Payment must accompany order.

Credit card number

Expiration date (MM/YY)

Signature for card authorization

To ensure uninterrupted membership to MedicAlert, your creditcard will be automatically charged a $35 renewal fee on yourrenewal date.q Check the box if you dont want us to charge your credit card for renewal.

Important:By accepting membership in MedicAlert Foundation you authorizeMedicAlert to release all medical and other condential information about you, inemergencies, and to other healthcare personnel you designate. MedicAlert relies upon

the accuracy of the information members supply. Member therefore agrees to defend,indemnify and hold MedicAlert (including its employees, ofcers, directors and agents)

harmless from any claim or l awsuit brought by member or others for injury, death,loss or damages arising in whole or in part out of members provision of incomplete or

inaccurate information to MedicAlert.

Signature of member(A parent or guardian signature is required for members under the age of 18.)

Date (MM/DD/YYYY)* MedicAlert Foundation is a 501(c)(3) nonprot organization that relies on contributions to

support our 24-hour emergency response center and our professional education efforts.Prices effective 01/2011 and subject to change without notice.

MedicAlert Advantage membership FREE S&H ($4.95) at www.medicalert.org - enter code 3733 Call 1.800.432.5378 Fax 1.800

Step 2 Information Step 3 Payment

ID Engraving: In an emergency, response personnel need to be aware of your criticalmedical information in order to treat you correctly. Your MedicAlert ID will be engraved

with your membership number and our 24-hour emergency response number to enableresponders to assist you immediately.

Please Note: Once your ID has been engraved and shipped, there will be an additionalcharge for any changes requested. ID engraving is personalized to individual

members and cannot be transferred to another individual, altered, sold, or returned. Tohelp assure you receive thorough, accurate treatment, the condition our trained staff

deems most relevant to your medical needs in an immediate emergency treatmentwill be engraved on your ID. No refunds will be issued.

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8/3/2019 Medic Alert Short Brochure

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2323 Colorado Avenue Turlock, CA 95382

1.800.ID.ALERT (1.800.432.5378) www.medicalert.org

10320 Rev.04

Rhodium Silver Teardrop Pendant(24 French Rope Chain)q A147 $109.95

Rhodium Silver Pendant(24" chain)q A010 $89.95

Sterling Silver Bracelet (Executive Chain)q A195 (large) $149.95q A201 (small) $139.95

Two-Tone Braceletq A096 (large) $24.95q A131 (small) $24.95

10K Gold Filled Charm Bracelet q A681 $129.95

Beaded Bracelet*

qA700 Blue $24.95 q A701 Pink $24.95q A702 Orange $24.95 (not shown)

Beaded Bracelet Lengthq 6" q 7" q 8"

*Beaded bracelets are not

recommended for daily wear orfor children under age 7

MedicAlert Watch withCitizen Eco-Drive Technologyq A724 (Womens) $139q A725 (Mens) $139

Mens Watch

MedicAlert Foundation is a 501(c)(3) nonprot organization. 2011 All rights reserved.MedicAlert is a U.S. registered trademark and service mark.

MedicAlert

ID

Stainless Steel Stretch Bandq A733 (large) $24.95q A734 (small) $24.95

Rhodium SilverPendant

Rhodium Silver

Teardrop Pendant

Sterling Silver Bracelet

Two-Tone Bracelet

Pink Beaded Bracelet

Blue BeadedBracelet

Stainless Steel Stretch Band

Visitwww.medicalert.orgto see full product selection. All IDs pictured on cover are actual size. Visit www.medicalert.org to see full product selection.

1.800.432.5378

www.medicalert.org

Dog Tag (Black)

Always There For You.SM

Stainless Steel

Bracelet (Red)

Stainless SteelBracelet (Green)

Stainless Steel

Pendant

q 5

q 8(When

How MedicAlert

Saves Lives

1

2

In an emergency, rst responders look for the

MEDICALERT ID and read the engraved information.

First responders can call the MedicAlert 24-hour

Emergency Response Center for additional critical

medical information.

The MedicAlert emergency response center calls

your designated contact so you or your loved one

are not alone in an emergency.

MedicAlert 24-hour emergency response service -

Always There For You.SM

Beaded Bracelet (Blue)

Stainless Steel Stretch Band10K Gold FilledCharm Bracelet

WomensWatch

FREE S&H ($4.95) at www.medicalert.org - enter promotional code 3733

MedicAlert Advantage membership (online offer only)

MEMBERSHIP

BENEFITS MedicAler t 24-hour

emergency response service

24-h our family noticationservice

Personalized MedicAlertwallet card

Personalized MedicAlert ID

Stainless

q Penda

q Dog Tq Dog T

(Neck

Braceletq Childq Red Mq Large

Additionaq A654 q A657 qA660 L

Shoe Tagq A661