NMA10E
JUL10
F
barcode:FPO
1484155
SERIAL NO.
MODEL NO.
Special Needs
MANUFACTURER
TYPE
Implants/Devices (include a copy of your implant card if possible)
No
Yes
Allergies/anaphylaxis Do you use an epinephrine injector?
All Current Medications (all prescription medications)
Medical Conditions (include any major surgeries or medical procedures)
Home Tel. (
2. Name
Home Tel. (
1. Name
)
)
Medical Conditions Recognized medical terminology and abbreviations will be used.
Engraving language
English
French
)
Alternate Tel. (
)
Relationship
Alternate Tel. (
)
Relationship
)
ext.
Tel. (
Personal Emergency Contacts (family/friends)
Specialty
ext.
Tel. (
Physician 2
Specialty
Physician 1
Emergency Medical Contacts
Alternate Tel. (
)
E-Mail
Postal Code
)
Parent/Guardian Information
)
__
Alternate Tel. (
Province/Territory
Prov.
ext.
Postal Code
Apt.
M
/
Yes, MedicAlert ID #
/
If ordering by phone or web, please mention this code number.
NMA10E
MedicAlert® is a registered trademark and service mark.
A National Registered Charity 10686 3293 RR0001.
Phone (
1484155
City
provider of the authentic
medical identification trusted
by health professionals since 1961
Address
barcode:FPO
Canadian MedicAlert® Foundation
If new member is a minor or an adult in the care of a guardian, please specify name of parent/guardian responsible for
keeping the member record up to date. Parent or guardian should be the first Personal Emergency contact.
Name
Relationship
quote this bar code # if enrolling by phone
• is a registered charity with the
mission to provide emergency
medical protection to all Canadians
who need it – you can always count
on us to protect you in a medical
emergency
Email
• An additional 1 year Product Care
on all MedicAlert identification products
)
• Family/emergency contact is notified
immediately after the hotline
is called
Best # to contact (
• trains and works with first responders
to look for the authentic MedicAlert
identification – crucial in assisting you
during a medical emergency
City
Advantage Membership
Offers the same comprehensive
Standard membership benefits,
plus
• has trained medical staff who review
your medical profile and determine
what is critical to communicate to first
responders in an emergency – vital to
saving your life when seconds count
French
If you answered yes,
you need MedicAlert
• Exclusive member value-added
information
Last Name
• 1 year Product Care on all bracelets
and necklaces
• has a 24-hour Emergency Hotline that
is available in 140 languages – stay
protected when you travel
Mailing Address
Visit www.medicalert.ca
for more information on various
charitable programs and how you can help
Diabetes, Allergies, Asthma
or any other condition
Only MedicAlert
English
MedicAlert is a registered charity
committed to protecting and saving
the lives of Canadians. We provide
first responders with access to members’
personal and medical information in an
emergency situation – regardless of
financial circumstances.
Do you have a medical condition?
• Follow-up with you after the initial
Emergency Hotline is contacted
First Name
4. The MedicAlert® 24-hour Emergency
Hotline can call your family and let them
know about your situation and where
you are
• MedicAlert wallet card listing detailed
emergency medical information
No
• Unlimited updates to your emergency
medical record
Are you, or have you ever been a MedicAlert member?
• Access to the 24-hour Emergency Hotline
for first responders
12630753
3. They can call the 24-hour Emergency
Hotline for your full MedicAlert
emergency medical record
(even if outside of Canada)
Mr.
When you wear authentic MedicAlert
identification, paramedics and doctors
have instant knowledge of your medical
condition and with one phone call
they gain immediate access to your
entire emergency medical record,
24-hours a day. When seconds count,
MedicAlert is Your Voice in an emergency.
Personal Information
H
9-634-4917 CO
E 20
LL
EC
LIN
ASTHMA
OT
TYPE 2 DIABETES
ALLERGIC TO NUTS
CARRIES EPIPEN
T
2. They look for your
critical condition(s)
engraved on
your MedicAlert
identification to
assist in your treatment
Standard Membership
• A customized MedicAlert identification
engraved with your most critical
health information
Gender
Imagine what would happen if you were
not diagnosed properly in an emergency.
Date of Birth (m/d/y)
What is included in your membership?
Communications
1. In a medical
emergency, first
responders look
for your MedicAlert
identification
Dr.
MedicAlert®
can save your life
Ms.
2 levels of membership
to choose from
Mrs.
Your Voice
in a medical emergency
1.
2.
3.
4.
5.
C 10K Gold bracelet (small emblem)
#700 / $449
Bead Bracelets
Measure your wrist and select according to available sizes:
Watch & Expansion Bracelet
Sport Bands
Q Designer stainless steel bracelet (large emblem)
#104 / $39
Q
T
ON, NB, NF
13.00%
Product Code #
AB, YT, NT, NU
5.00%
SK
10.00%
/
PEI
15.50%
Product Name
QC
12.88%
Bracelet/Watch
Size
Shipping & Handling
Total
(add lines F, G & H)
Donation
Membership Fee
Subtotal
(add lines D & E)
Taxable Amount
(add lines A, B & C)
Sales Tax
(Line D x prov. tax from chart on left)
National Registered Charity # 10686 3293 RR0001
A
B
C
D
E
F
G
H
Expiry Date (month/year)
American Express
METHOD OF PAYMENT
MasterCard
/
Signature
)
❑guardian
8.99
Price
$
Date
Gold and Silver products are Nickel free.
inches
1
8
7
6
5
4
3
2
✂
Order Form - shaded areas must be filled in
BC, MB
12.00%
VISA
QST Reg. #1022707074
Money Order
GST/HST Registration # 10686 3293
Cheque
/
Please make cheque payable to Canadian MedicAlert® Foundation
Credit Card #
Signature
Name (print)
Phone Number (
Relationship to member ❑self
❑other (Specify)
COMPLIMENTARY RULER. Measure your wrist size and refer to complete sizing information on opposite page.
If not the member, I have the authority to bind the member.
❑parent
• MedicAlert, its officers, directors, employees and representatives, will not be liable for any claims,
actions, damages, losses or consequences of any kind arising out of or in connection with any errors
or omissions in my Personal Information (regardless of whether such information is provided by me
or by a third party); MedicAlert may use aggregate health information, which is not in a form that
identifies me or any other individual, for research projects or studies of interest to the health care
community; and
• unless I have checked the applicable box below, I will receive by e-mail or any other method of
communication chosen by MedicAlert, informational mailings such as the MedicAlert newsletter and
information on charitable works, programs and services that may be of interest to me (“Informational
Mailings”);
❑ Do not send me Informational Mailings
❑ Send me Informational Mailings by ordinary post only.
• I UNDERSTAND that I may obtain a copy of MedicAlert’s privacy policy, more information about its
privacy practices and information about accessing or correcting my Personal Information on
MedicAlert’s website at http://www.medicalert.ca or by calling MedicAlert’s Chief Privacy Officer at
1.866.492.0939.
Ensure you read and sign the member statement below
Name as it appears on card
Member Statement
Membership with the Canadian MedicAlert® Foundation ("MedicAlert") is conditional on an
individual’s acceptance of the following terms and conditions (the "Member Statement").
I ACKNOWLEDGE and agree that:
• on my becoming a member, MedicAlert will create and maintain, an electronic member record
(“File”) containing personal and personal health information that I provide or arrange to have
provided to MedicAlert (together “my Personal Information”), which File will be identified by my
name and held at 2005 Sheppard Avenue East, Suite 800, Toronto, Ontario M5J 5B4 and will provide
me with: i) a custom engraved MedicAlert bracelet, necklet or watch; ii) the 24-hour MedicAlert
Emergency Hotline service; iii) a MedicAlert membership card and iv) secure web based access to
my File (collectively the “Services”);
• MedicAlert will use and disclose my Personal Information for the purposes of providing and
administering the Services, including without limitation, providing my Personal Information to
emergency responders and other health professionals (collectively “Responders”) who contact
MedicAlert, may transfer my Personal Information to third party service providers retained by
MedicAlert to assist it in administering or providing the Services where necessary for the provision of
the Services, and will allow MedicAlert Foundation International, which operates in the USA, access
to my File for the purpose of providing the MedicAlert Emergency Hotline;
• I will advise MedicAlert promptly of any error on my File, MedicAlert bracelet, necklet or watch or
membership card, update my File information at least once per year and pay any and all service
fees associated with my membership on or before the renewal date of my membership and I
understand that if I do not pay applicable service fees or have not updated my File, MedicAlert will
stop providing me with regular Services
• MedicAlert or Responders may contact the emergency contacts I have provided for or with
information about me in case of an emergency and MedicAlert will accept information about my
health from emergency contacts and guardians listed in my File, provided the contacts and guardians
know my member number; full name, date of birth, and address, but will not disclose my Personal
Information unless I have instructed otherwise;
/
To ensure continued protection and service, I hereby authorize MedicAlert to charge the applicable annual service fee to my credit
card each year on the renewal date of my membership. I will advise MedicAlert of any change in my credit card information.
Your donation to MedicAlert can help protect and save lives.
Membership must be selected and price placed in box G
Standard
1 yr = $39
Advantage
1 yr = $49
NS
15.00%
Select an identification product from the Identify yourself in Style page in this brochure or go to www.medicalert.ca
Measure your wrist size if ordering a bracelet or watch
Place the product code, product name, preferred size (sizing information on product page) and price in the appropriate columns
Fill out the order form as directed (combined provincial tax, membership level, payment options, etc.)
Mail completed order form to: Canadian MedicAlert Foundation, 2005 Sheppard Ave. E., Suite 800, Toronto ON M2J 5B4
If you require assistance, please contact us at 1.877.250.5738
* Made with CRYSTALLIZEDTM
– Swarovski Elements
U
®
R Black sport band with Velcro closure
(small emblem)
#209 / $40
1. Online: www.medicalert.ca/enrol
2. Phone: (toll-free) 1.877.250.5738 (Monday-Friday; 9am - 5pm EST)
3. Mail: complete the order form (front and back) and mail to:
Canadian MedicAlert Foundation
2005 Sheppard Ave. East, Suite 800, Toronto, ON M2J 5B4
Prices shown do not include taxes or shipping.
Prices, selection and availability are subject
to change without notice.
Measure your wrist and select according to available sizes:
V
NOTE: Order next full size up if required (e.g. wrist measures 5¼”,
select size small). Band sizes are not adjustable.
N
P Stainless steel bracelet (small emblem)
#100 / $39
• A paper ruler has been provided for you on the order form.
G
Product Care Program: MedicAlert® provides warranty on the workmanship
and material of your bracelet and/or necklace for one year and a Manufacturer’s
five year limited warranty on watches. An additional 1 year warranty applies
to all new identification products as part of the Advantage Membership. Any
repairs or modifications to the product must be made by MedicAlert. A resizing
fee may apply.
Cancellation Policy: Cancellation fee applies once registration is processed.
Refund Policy: There are no refunds on bracelets, necklaces and/or watches
due to the customized engraving of medical information.
3 easy ways to enrol
R
V Men’s Luminous Citizen Watch
#110 / $149 Ladies also available
Chain Bracelets
J* Vintage Platinum Pearl bracelet with small
sterling silver emblem
#431 / $89
NOTE: For wrist products – the total length of the product
you select includes the emblem, chain (band) and clasp.
S
Pink and Purple Flower sport band
with buckle closure (small emblem)
#214 / $40
T
Small
- fits 6" to 6 ½"
Medium - fits 7" to 7 ½"
Large
- fits 8" to 8 ½"
O
O Designer silver expansion band
#406 / $130
Necklaces: Not suitable for children under the age of 10.
Beaded products: Not sold for children under the age of 3.
U Dog Tag, stainless steel with 30" beaded chain
#106 / $39 Black Dog Tag also available
Velcro® Closure Sport Bands:
Measure your wrist and select according to available sizes:
Size 6”, 7”, 8”, 9”, or 10” NOTE: Order next full size up if required
P
Green Camouflage sport band with buckle
closure (small emblem)
#223 / $40
M
M Chelsea sterling silver bracelet
#423 / $149
Size 6 - fits wrist size up to 6”
Size 7 - fits wrist size up to 7”
Size 8 - fits wrist size up to 8”
J
L* Sapphire Roxy bracelet with small sterling
silver emblem
#440 / $129
• Using a ruler and a string, measure your wrist and follow the
instructions based on your product preference.
H Liberty Drop
#438 / $89
NOTE: Order next full size up if required (e.g. wrist measures 6¼”,
select size 7)
N Victoria sterling silver necklace with
20" chain, lobster clasp
#413 / $90
Available in ½ and full inch increments. Measure your wrist and add
a ½ inch. NOTE: When measurement is ¼ size order next ½ size up
(e.g. wrist measures 5¾” + ½” = 6¼”, select size 6½”)
C
K* Cream Rose Pearl bracelet with small
sterling silver emblem
#428 / $89
Instructions for measuring your wrist
K
D
E
Silver Dog Tag 1.375"
Round Emblem .75"
B
G Liberty Sport necklace with silver Liberty
Drop, 20" latex-free rubber necklace,
lobster clasp
#434 / $99
Buckle Sport Bands:
Measure your wrist and select according to available sizes:
Small
- fits 4" - 5 ½"
Medium - fits 5" - 7"
Large
- fits 6" - 8 ½"
S
Liberty silver bangle with removable
silver Liberty Drop (one size)
#433 / $149
F
H
E London Dog Tag polished sterling silver
#447 / $89 Brushed silver also available
Large 1.50”
Small 1.25”
L
A
Bracelet Emblems
(Actual Size)
Visit www.medicalert.ca for our complete product line
Figaro sterling silver bracelet (large emblem)
#410 / $99 Small emblem also available
B
F
D London Dog Tag Sport necklace
with polished silver medallion, 22" or 24"
latex-free rubber necklace, lobster clasp
#444 / $99
Brushed silver medallion also available
Sizing Information
Identify yo u r s e l f i n S t y l e
A Sterling silver bracelet (small emblem)
#400 / $85
3 easy ways to enrol
U
Prices shown do not include taxes or shipping.
Prices, selection and availability are subject
to change without notice.
* Made with CRYSTALLIZEDTM
– Swarovski Elements
V Men’s Luminous Citizen Watch
#110 / $149 Ladies also available
Pink and Purple Flower sport band
with buckle closure (small emblem)
#214 / $40
T
U Dog Tag, stainless steel with 30" beaded chain
#106 / $39 Black Dog Tag also available
Green Camouflage sport band with buckle
closure (small emblem)
#223 / $40
S
R Black sport band with Velcro closure
(small emblem)
#209 / $40
®
Q Designer stainless steel bracelet (large emblem)
#104 / $39
P Stainless steel bracelet (small emblem)
#100 / $39
O Designer silver expansion band
#406 / $130
V
N Victoria sterling silver necklace with
20" chain, lobster clasp
#413 / $90
M Chelsea sterling silver bracelet
#423 / $149
L* Sapphire Roxy bracelet with small sterling
silver emblem
#440 / $129
K* Cream Rose Pearl bracelet with small
sterling silver emblem
#428 / $89
J* Vintage Platinum Pearl bracelet with small
sterling silver emblem
#431 / $89
H Liberty Drop
#438 / $89
G Liberty Sport necklace with silver Liberty
Drop, 20" latex-free rubber necklace,
lobster clasp
#434 / $99
Liberty silver bangle with removable
silver Liberty Drop (one size)
#433 / $149
F
E London Dog Tag polished sterling silver
#447 / $89 Brushed silver also available
D London Dog Tag Sport necklace
with polished silver medallion, 22" or 24"
latex-free rubber necklace, lobster clasp
#444 / $99
Brushed silver medallion also available
C 10K Gold bracelet (small emblem)
#700 / $449
B
C
A
P
R
O
E
Gold and Silver products are Nickel free.
T
Q
J
D
S
M
K
L
Visit www.medicalert.ca for our complete product line
Figaro sterling silver bracelet (large emblem)
#410 / $99 Small emblem also available
B
1. Online: www.medicalert.ca/enrol
2. Phone: (toll-free) 1.877.250.5738 (Monday-Friday; 9am - 5pm EST)
3. Mail: complete the order form (front and back) and mail to:
Canadian MedicAlert Foundation
2005 Sheppard Ave. East, Suite 800, Toronto, ON M2J 5B4
Product Care Program: MedicAlert® provides warranty on the workmanship
and material of your bracelet and/or necklace for one year and a Manufacturer’s
five year limited warranty on watches. An additional 1 year warranty applies
to all new identification products as part of the Advantage Membership. Any
repairs or modifications to the product must be made by MedicAlert. A resizing
fee may apply.
Cancellation Policy: Cancellation fee applies once registration is processed.
Refund Policy: There are no refunds on bracelets, necklaces and/or watches
due to the customized engraving of medical information.
NOTE: For wrist products – the total length of the product
you select includes the emblem, chain (band) and clasp.
Necklaces: Not suitable for children under the age of 10.
Beaded products: Not sold for children under the age of 3.
Velcro® Closure Sport Bands:
Measure your wrist and select according to available sizes:
Size 6”, 7”, 8”, 9”, or 10” NOTE: Order next full size up if required
Buckle Sport Bands:
Measure your wrist and select according to available sizes:
Small
- fits 4" - 5 ½"
Medium - fits 5" - 7"
Large
- fits 6" - 8 ½"
Sport Bands
NOTE: Order next full size up if required (e.g. wrist measures 5¼”,
select size small). Band sizes are not adjustable.
F
G
H
N
Small
- fits 6" to 6 ½"
Medium - fits 7" to 7 ½"
Large
- fits 8" to 8 ½"
Measure your wrist and select according to available sizes:
Watch & Expansion Bracelet
NOTE: Order next full size up if required (e.g. wrist measures 6¼”,
select size 7)
Size 6 - fits wrist size up to 6”
Size 7 - fits wrist size up to 7”
Size 8 - fits wrist size up to 8”
Measure your wrist and select according to available sizes:
Bead Bracelets
Available in ½ and full inch increments. Measure your wrist and add
a ½ inch. NOTE: When measurement is ¼ size order next ½ size up
(e.g. wrist measures 5¾” + ½” = 6¼”, select size 6½”)
• A paper ruler has been provided for you on the order form.
Chain Bracelets
• Using a ruler and a string, measure your wrist and follow the
instructions based on your product preference.
Instructions for measuring your wrist
Silver Dog Tag 1.375"
Round Emblem .75"
Large 1.50”
Small 1.25”
Bracelet Emblems
(Actual Size)
Sizing Information
Identify yo u r se l f i n S t y l e
A Sterling silver bracelet (small emblem)
#400 / $85
Select an identification product from the Identify yourself in Style page in this brochure or go to www.medicalert.ca
Measure your wrist size if ordering a bracelet or watch
Place the product code, product name, preferred size (sizing information on product page) and price in the appropriate columns
Fill out the order form as directed (combined provincial tax, membership level, payment options, etc.)
Mail completed order form to: Canadian MedicAlert Foundation, 2005 Sheppard Ave. E., Suite 800, Toronto ON M2J 5B4
If you require assistance, please contact us at 1.877.250.5738
Order Form - shaded areas must be filled in
Bracelet/Watch
Size
Product Name
Price
A
B
Shipping & Handling
C
Taxable Amount
(add lines A, B & C)
Sales Tax
(Line D x prov. tax from chart on left)
D
Subtotal
(add lines D & E)
F
Membership must be selected and price placed in box G
Standard
1 yr = $39
Advantage
1 yr = $49
Membership Fee
G
Your donation to MedicAlert can help protect and save lives.
Donation
H
AB, YT, NT, NU
5.00%
ON, NB, NF
13.00%
NS
15.00%
BC, MB
12.00%
SK
10.00%
QC
12.88%
PEI
15.50%
$
8.99
E
Total
(add lines F, G & H)
To ensure continued protection and service, I hereby authorize MedicAlert to charge the applicable annual service fee to my credit
card each year on the renewal date of my membership. I will advise MedicAlert of any change in my credit card information.
GST/HST Registration # 10686 3293
QST Reg. #1022707074
National Registered Charity # 10686 3293 RR0001
METHOD OF PAYMENT
Cheque
Money Order
VISA
MasterCard
American Express
Please make cheque payable to Canadian MedicAlert® Foundation
Credit Card #
/
/
Expiry Date (month/year)
/
Name as it appears on card
/
Signature
Ensure you read and sign the member statement below
Member Statement
Membership with the Canadian MedicAlert® Foundation ("MedicAlert") is conditional on an
individual’s acceptance of the following terms and conditions (the "Member Statement").
I ACKNOWLEDGE and agree that:
• on my becoming a member, MedicAlert will create and maintain, an electronic member record
(“File”) containing personal and personal health information that I provide or arrange to have
provided to MedicAlert (together “my Personal Information”), which File will be identified by my
name and held at 2005 Sheppard Avenue East, Suite 800, Toronto, Ontario M5J 5B4 and will provide
me with: i) a custom engraved MedicAlert bracelet, necklet or watch; ii) the 24-hour MedicAlert
Emergency Hotline service; iii) a MedicAlert membership card and iv) secure web based access to
my File (collectively the “Services”);
• MedicAlert will use and disclose my Personal Information for the purposes of providing and
administering the Services, including without limitation, providing my Personal Information to
emergency responders and other health professionals (collectively “Responders”) who contact
MedicAlert, may transfer my Personal Information to third party service providers retained by
MedicAlert to assist it in administering or providing the Services where necessary for the provision of
the Services, and will allow MedicAlert Foundation International, which operates in the USA, access
to my File for the purpose of providing the MedicAlert Emergency Hotline;
• I will advise MedicAlert promptly of any error on my File, MedicAlert bracelet, necklet or watch or
membership card, update my File information at least once per year and pay any and all service
fees associated with my membership on or before the renewal date of my membership and I
understand that if I do not pay applicable service fees or have not updated my File, MedicAlert will
stop providing me with regular Services
• MedicAlert or Responders may contact the emergency contacts I have provided for or with
information about me in case of an emergency and MedicAlert will accept information about my
health from emergency contacts and guardians listed in my File, provided the contacts and guardians
know my member number; full name, date of birth, and address, but will not disclose my Personal
Information unless I have instructed otherwise;
• MedicAlert, its officers, directors, employees and representatives, will not be liable for any claims,
actions, damages, losses or consequences of any kind arising out of or in connection with any errors
or omissions in my Personal Information (regardless of whether such information is provided by me
or by a third party); MedicAlert may use aggregate health information, which is not in a form that
identifies me or any other individual, for research projects or studies of interest to the health care
community; and
• unless I have checked the applicable box below, I will receive by e-mail or any other method of
communication chosen by MedicAlert, informational mailings such as the MedicAlert newsletter and
information on charitable works, programs and services that may be of interest to me (“Informational
Mailings”);
❑ Do not send me Informational Mailings
❑ Send me Informational Mailings by ordinary post only.
• I UNDERSTAND that I may obtain a copy of MedicAlert’s privacy policy, more information about its
privacy practices and information about accessing or correcting my Personal Information on
MedicAlert’s website at http://www.medicalert.ca or by calling MedicAlert’s Chief Privacy Officer at
1.866.492.0939.
Signature
COMPLIMENTARY RULER. Measure your wrist size and refer to complete sizing information on opposite page.
Product Code #
inches
1
✂
1.
2.
3.
4.
5.
2
3
4
5
6
7
Date
Name (print)
Phone Number (
)
Relationship to member ❑self
❑parent
❑guardian
❑other (Specify)
If not the member, I have the authority to bind the member.
8
ext.
Personal Emergency Contacts (family/friends)
Medical Conditions Recognized medical terminology and abbreviations will be used.
Engraving language
English
French
Medical Conditions (include any major surgeries or medical procedures)
All Current Medications (all prescription medications)
SERIAL NO.
MedicAlert®
can save your life
Emergency Medical Contacts
2 levels of membership
to choose from
E-Mail
Your Voice
in a medical emergency
Tel. (
Imagine what would happen if you were
not diagnosed properly in an emergency.
Specialty
What is included in your membership?
ext.
Standard Membership
• A customized MedicAlert identification
engraved with your most critical
health information
Relationship
1. Name
• Access to the 24-hour Emergency Hotline
for first responders
MODEL NO.
When you wear authentic MedicAlert
identification, paramedics and doctors
have instant knowledge of your medical
condition and with one phone call
they gain immediate access to your
entire emergency medical record,
24-hours a day. When seconds count,
MedicAlert is Your Voice in an emergency.
MANUFACTURER
• Unlimited updates to your emergency
medical record
Only MedicAlert
• has a 24-hour Emergency Hotline that
is available in 140 languages – stay
protected when you travel
Tel. (
1. In a medical
emergency, first
responders look
for your MedicAlert
identification
12630753
Do you have a medical condition?
Diabetes, Allergies, Asthma
or any other condition
T
1484155
TYPE
9-634-4917 CO
E 20
LL
EC
LIN
ASTHMA
OT
TYPE 2 DIABETES
ALLERGIC TO NUTS
CARRIES EPIPEN
• MedicAlert wallet card listing detailed
emergency medical information
• Follow-up with you after the initial
Emergency Hotline is contacted
• 1 year Product Care on all bracelets
and necklaces
If you answered yes,
you need MedicAlert
Relationship
2. Name
barcode:FPO
Implants/Devices (include a copy of your implant card if possible)
No
Yes
Allergies/anaphylaxis Do you use an epinephrine injector?
2. They look for your
critical condition(s)
engraved on
your MedicAlert
identification to
assist in your treatment
3. They can call the 24-hour Emergency
Hotline for your full MedicAlert
emergency medical record
(even if outside of Canada)
• Exclusive member value-added
information
• has trained medical staff who review
your medical profile and determine
what is critical to communicate to first
responders in an emergency – vital to
saving your life when seconds count
• trains and works with first responders
to look for the authentic MedicAlert
identification – crucial in assisting you
during a medical emergency
• is a registered charity with the
mission to provide emergency
medical protection to all Canadians
who need it – you can always count
on us to protect you in a medical
emergency
Email
Parent/Guardian Information
If new member is a minor or an adult in the care of a guardian, please specify name of parent/guardian responsible for
keeping the member record up to date. Parent or guardian should be the first Personal Emergency contact.
Name
Relationship
F
If ordering by phone or web, please mention this code number.
Special Needs
Advantage Membership
Offers the same comprehensive
Standard membership benefits,
plus
Canadian MedicAlert® Foundation
provider of the authentic
medical identification trusted
by health professionals since 1961
Physician 2
)
)
Alternate Tel. (
)
Home Tel. (
• Family/emergency contact is notified
immediately after the hotline
is called
• An additional 1 year Product Care
on all MedicAlert identification products
1484155
JUL10
quote this bar code # if enrolling by phone
barcode:FPO
MedicAlert® is a registered trademark and service mark.
A National Registered Charity 10686 3293 RR0001.
Specialty
)
)
Alternate Tel. (
)
Home Tel. (
4. The MedicAlert® 24-hour Emergency
Hotline can call your family and let them
know about your situation and where
you are
MedicAlert is a registered charity
committed to protecting and saving
the lives of Canadians. We provide
first responders with access to members’
personal and medical information in an
emergency situation – regardless of
financial circumstances.
Visit www.medicalert.ca
for more information on various
charitable programs and how you can help
NMA10E
NMA10E
Physician 1
Postal Code
Prov.
City
Address
ext.
)
Alternate Tel. (
__
)
Best # to contact (
Postal Code
Province/Territory
City
M
/
/
Date of Birth (m/d/y)
French
English
Communications
)
Alternate Tel. (
)
Phone (
Apt.
Mailing Address
Dr.
Gender
Ms.
Mrs.
Mr.
Last Name
First Name
Yes, MedicAlert ID #
No
Are you, or have you ever been a MedicAlert member?
H
Personal Information