Sign-Up or Modify
Once you have completed the form below, please don't forget to visit our On-Line shop where you can pay for your membership.
Updates of your information in our database are FREE to members who have paid their annual subscription. Otherwise an Admin fee will be charged.
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Where did you come to hear about MedicAlert ?
Select One or More
Word of Mouth
Preferred Contact Method
Monthly Newsletter ?
Receive SMS Updates ?
Medical Aid details on Bracelet ?
Hospital Plan Name
Hospital Plan #
Hospital Folder #
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Medical Condition (300 chars left)
Please enter the members Medical information to be kept in our database
# MedicAlert will engrave the most vital medical information on your emblem and retain all pertinent info in the computerized file. Please call if you wish to discuss engraving.
# Medical Aid details frequently change, and thus would require a new emblem (at members cost) if details are engraved. The alternative wording would be On Medical Aid, and the details kept on our database.
# Engraving space is limited by size of emblem.
(Always have one space between words)
Confirm Database & Bracelet Engraving
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By entering your NAME, SURNAME and TODAYS DATE below, you accept membership of MedicAlertÂ®, and authorise MedicAlertÂ® to release information in emergencies or to healthcare personnel whom you designate.
Your application has been received.
A copy of the application has been E-mailed to you.
Please visit out On-Line shop to pay for your
membership or annual renewal fee.
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