Order Form for the HEALTHFIT Card (Please Print)
Please fill in all blanks and carefully and sign at the bottom.  All information provided to HealthFIT Services is kept in the strictest confidence.



_________________________________________________________________________________________________
     First Name                       Middle Name                   Last Name                        Social Security Number



__________________________________(_______)________________________________/________/_____________
     Mailing Address                                   Phone                                                         Date of Birth



_________________________________________________________________________________________________
     City                                                    State                         Zip                                           Email



____________________________(______)_____________________________________________(______)_________
     Physician                                 Phone                             Emergency Contact                          Phone



_________________________________________________________________________________________________
     Allergies



_________________________________________________________________________________________________
     Medications (please include the dosage and frequency of all medications)



_________________________________________________________________________________________________
Medical History-Please circle all that apply
     Heart Attack

     Rheumatic Heart Disease

     Angina

     Artificial Heart Valve

     Bypass Surgery  (# of vessels __________)

     Kidney Disease		 Y              N

Y              N

Y              N

Y              N

Y              N

Y              N
    Congestive Heart Failure

     High Blood Pressure

     Contact Lenses

     Diabetes

     Epilepsy

     Stroke/TIA
Y             N

Y             N

Y             N

Y             N

Y             N

Y             N
     Pacemake (model # and Manufacturer) ____________________________________________________________

     Other (Specify):  ______________________________________________________________________________
The previous information which has been provided to HealthFIT Services by the undersigned applicant is to be transcribed onto a plastic card.  No representation or guarantee is made by HealthFIT Services as to the accuracy of the information furnished by the applicant or the effectiveness of said information at reducing the applicant's medical charges, costs or the necessity of any medical testing deemed necessary by a licensed physician.
Card Selection                                                                                Method of Payment
Check/Money Order          Check#__________
A card with an EKG for $25

A card without an EKG for $20

A duplicate card for $10

Each year, please charge my credit card $15 to continue my annual membership.

Each year, please send me a bill for $15 to continue my annual membership.
MasterCard
Visa
Please add 6% sales tax and $1.95 for Shipping and Handling


_________________________________________________
Credit Card #                                                   Exp. Date


_________________________________________________
Signature
(A signature is required for processing all forms of payment)
HealthFIT Services
2604 N Rosegarden Blvd
Mechanicsburg, PA  17055
Toll Free:  1-877-494-1285
Fax:  270-514-8612
[email protected]
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