THIS CARD COULD SAVE YOUR LIFE

The MEDICAL I.D. CARD is a plastic wallet size card containing your personal medical data. In case of emergency the card is easily read by others without being magnified.  Any medical data that might help a doctor act faster should be on your card, such as drug allergies, diabetes, heart trouble, hypertension and other conditions. The Medical I.D. Card saves lives and it can save yours too.


EMERGENCY MEDICAL INFORMATION

Please take a few moments and accurately fill out the survey form so your information is valid.

 
Full Name: Street Address:
City/State/Zip: Phone Number:
Date of Birth: Social Security #:
Please notify: Phone #:
Physician: Phone #:
Insurance Company:
Policy #:
  BLOOD TYPEA+ A- B+ B- O+ O- AB+ AB- UNKNOWN

BLOOD PRESSUREHIGH NORMAL LOW

PLEASE CHECK THE APPROPRIATE BOXES
 
Diabetes  Anemia  Heart Trouble 
Pacemaker  Hepatitis  Emphysema 
 
Kidney or Liver Disorder  Contact Lenses 
Hemophilia  Asthma
  Other Disorders:

ALLERGIES

 
Iodine  Sulfa  Penicillin 
  Other Allergies:

Taking the following medication:

I CERTIFY ALL INFORMATION IS ACCURATE TO THE BEST OF MY KNOWLEDGE.

Signature: Date: 

IF CARD HOLDER IS UNDER 18. PARENT OR GUARDIAN MUST SIGN.

Please print, sign and mail the above info along with a check or money order of $5.95 to:

Mary Varner
P.O. Box 1135
Trenton, Georgia 30752


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