Print this medical I.D. form and send Your Information to:

Medical Alert
P.O. Box 29284
Columbus, Ohio
43229-0284

Full name: __________________________________________________

Address: _____________________________________________________

City: __________________________ State: ____________________

Zip: _______________ Telephone: (___)_____________

Birthdate: ______________ Social Security: ___________________

Please Notify: ___________________ Telephone: (___)____________

Blood Type (if known):_____________ Religion: ___________________

Physican:______________________Telephone: (___) _______________

Medications for: ______________________________________

_______________________________________________________

Allergies: _____________________________________________

Signature:____________________________ Date:____________________

Please make your check or money order out to Candis James and include $14.00 for each card ordered. The Medical I.D. card will be sent to the address listed on the form.

If you have Questions Please contact: CandisJamesRN@yahoo.com

Thank you for your order