MedicAlert Advantage membership FREE S&H ($4.95) at www.medicalert.

org - enter code 3733

Call 1.800.432.5378

Fax 1.800.863.3429

Mail This Form

Step 2 Information
(Please print clearly)

Step 3 Payment
Enrollment Enrollment in the MedicAlert Advantage Service includes creation and management of your MedicAlert Emergency Medical Information Record (EMIRSM), a MedicAlert Wallet Card with your emergency information imprinted, secure online access to your MedicAlert Emergency Medical Record, and the MedicAlert Emergency Response Service 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 Select your product(s):
Order r online fo rd nda FREE Sta S&H

MedicAlert membership benefits:

Personalized MedicAlert ID 24-hour MedicAlert emergency response service 24-hour family notification service Secure MedicAlert emergency medical record including: - Family contact information - Medical information Online access, unlimited updates to your MedicAlert emergency medical record MedicAlert wallet card
MedicAlert 24-hour emergency response number

Personal Information
q Yes q No

(Please print clearly)

Medical Conditions/Allergies

Previous/current MedicAlert member?

If yes, enter member number Last four digits of SSN

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

q Dr.
First name Last name

q Mr.

q Mrs.

q Ms.

q Miss

$39.95

Middle name/initial Suffix

Price Price Charitable contribution* Shipping and handling TOTAL $4.95

Mailing address

FedEx shipping additional $10 (required with watch orders) q No known medical conditions
State Zip

City

(
Phone

)
q M q F

(Please print clearly) *List all medications and dosages, including inhalers. Medication Prescribed Dosage

Medications

Method of payment q Check q Money Order q MasterCard q Visa q Discover q AMEX No 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 credit card will be automatically charged a $35 renewal fee on your renewal date. q Check the box if you dont want us to charge your credit card for renewal.

Gender

Date of birth (MM/DD/YYYY) E-mail address

Emergency Contacts
*Primary contact to notify/relationship

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

Primary contacts phone

Primary contacts second phone

*Second contact to notify/relationship

Secondary contacts phone Primary physician/specialty

Secondary contacts second phone

ID Engraving: In an emergency, response personnel need to be aware of your critical medical 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 enable responders to assist you immediately. Please Note: Once your ID has been engraved and shipped, there will be an additional charge for any changes requested. ID engraving is personalized to individual members and cannot be transferred to another individual, altered, sold, or returned. To help assure you receive thorough, accurate treatment, the condition our trained staff deems most relevant to your medical needs in an immediate emergency treatment will be engraved on your ID. No refunds will be issued.

Important: By accepting membership in MedicAlert Foundation you authorize MedicAlert to release all medical and other confidential information about you, in emergencies, 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, officers, directors and agents) harmless from any claim or lawsuit 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.

Your vital medical information

Your MedicAlert member number

Phone Health insurer Group plan number Insurer member number

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) nonprofit 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.

MedicAlerts immediate response dramatically improves the chances for survival.

Charlotte Yeh, MD
former Chief of Emergency Medicine New England Medical Center, Boston, MA

*Only contacts listed can update members record.

MedicAlert ID

How MedicAlert Saves Lives

Step 1 Select
Dog Tag

Rhodium Silver Teardrop Pendant (24 French Rope Chain) q A147 $109.95 Rhodium Silver Pendant (24" chain) q A010 $89.95
Rhodium Silver Teardrop Pendant Rhodium Silver Pendant

1
In an emergency, first responders look for the MEDICALERT ID and read the engraved information.

Always There For You.

Dog Tag (Black)

SM

Black Dog Tag

Pendant

Sterling Silver Bracelet

Stainless Steel Products

Stainless Steel Pendant

Sterling Silver Bracelet (Executive Chain) q A195 (large) $149.95 q A201 (small) $139.95 Two-Tone Bracelet q A096 (large) $24.95 q A131 (small) $24.95
10K Gold Filled Charm Bracelet Two-Tone Bracelet

2
First responders can call the MedicAlert 24-hour Emergency Response Center for additional critical medical information.

q Pendant (26" chain) A017

$9.95

q Dog Tag (30" beaded chain) A601 $9.95 q Dog Tag-Black (30" black beaded chain) A600 $9.95 (Necklaces not recommended for small children)
Childs Medical ID

10K Gold Filled Charm Bracelet q A681 $129.95

Red Medical ID

Stainless Steel Stretch Band q A733 (large) $24.95 q A734 (small) $24.95
Blue Beaded Bracelet

Stainless Steel Stretch Band

3
The MedicAlert emergency response center calls your designated contact so you or your loved one are not alone in an emergency.
Stainless Steel Bracelet (Green)

Stainless Steel Stretch Band

BENEFITS
MedicAlert 24-hour emergency response service 24-hour family notification service Personalized MedicAlert wallet card
Stainless Steel Bracelet (Red)

MEMBERSHIP

Bracelet q Childs Medical ID A156 q Red Medical ID A126 q Large Red Medical ID (not shown) A091
Purple

$9.95 $9.95 $9.95

Black

Beaded Bracelet* q A700 Blue $24.95 q A702 Orange $24.95 (not shown) Beaded Bracelet Length q 6" q 7" q 8"

Pink Beaded Bracelet

q A701 Pink $24.95

*Beaded bracelets are not recommended for daily wear or for children under age 7

4
MedicAlert 24-hour emergency response service Always There For You.SM 2323 Colorado Avenue Turlock, CA 95382 1.800.ID.ALERT (1.800.432.5378) www.medicalert.org
FREE S&H ($4.95) at www.medicalert.org - enter promotional code 3733 MedicAlert Advantage membership (online offer only)
MedicAlert Foundation is a 501(c)(3) nonprofit organization. 2011 All rights reserved. MedicAlert is a U.S. registered trademark and service mark.
10320 Rev.04

Pink

Personalized MedicAlert ID
Beaded Bracelet (Blue)

Additional Colors $9.95 q A654 Light Blue q A655 Blue q A657 Green q A658 Pink q Lilac A660 q A663 Teal

q A656 Orange q A659 Purple q A739 Black

MedicAlert Watch with Citizen Eco-Drive Technology q A724 (Womens) $139 q A725 (Mens) $139
Mens Watch

Shoe Tag q A661 $9.95

Womens Watch

Visit www.medicalert.org to see full product selection.

1.800.432.5378 www.medicalert.org
All IDs pictured on cover are actual size. Visit www.medicalert.org to see full product selection.

q 5 q 8

(When selecting, please measure your wrist snugly and add )

q 5 q 8

Bracelet Sizes q 6 q 6 q 7 q 9

q 7