MedicAlert® New Membership Application Form
Current member
Registration No.
Date of Birth
Sex
Yes No
Male Female
Member's Details   ID/Passport No.
Surname First Name Init:              Email Address Phone Nos.
Home Address
Postal Address
Home:

Work:

Cell:
Next of Kin (N.O.K.)    
Surname First Name Phone Nos.
Home Address
Home:

Work:

Cell:
Doctors Details   Name: NAMAS No. Hosp/Clinic Name:  
:
 Address: Phone: Cell:
MARS Tel: Yes No Medical Aid No. Name of Medical Aid Society
Medical Details
Blood Group (if known)    
Medical Practitioner, please tick which major problem and.or allergies should be engraved on the Emblem
Medical Problems
Allergies
  
Alzheimer's Disease Haemophilia Anaesthetics Penicillin
Angina Heart Condition Analgesics Streptomycin
Aortic Valve Prosthesis Hypoglycaemia Antidepressants Sulphas
Arthritis H.I.V. Positive Aspirin Tetracycline
Asthma Hypertension Barbiturates Tetanus Toxoid
Blind Joint Replacement Codeine  
Cataracts Migraine Headaches Cortisone Special Notes
Deaf & Dumb Pacemaker Elastoplast Frequent Traveller
Diabetes (insulin) Porphyria Erythromycin Jogger
Diabetes (non insulin) Prosthesis Insect/Bee Stings Scuba Diver
Epilepsy Renal Failure/Haemodialysis Iodine Identity only
Emphysema Sickle Cell Anaemia I.V.P.Dye M.A.R.S. only
Glaucoma Contact Lenses Morphine Living Will
G6PD Deficient      
Other medical:..................................................... Other allergy:................................................
Current Medication:
Doctor's Signature: Date:
MedicAlert® Membership Order
(Emblems are shown in actual size. Plese tick appropriate box)
Bracelet Type C
Bracelet Type B
Necklace Type A
(66cm chain (approx)) 
 
Membership
& Stainless Steel
Emblem 		US$ 20
( plus P+P )
10 carat gold infill US$150 (Type B), and Silver infill emblems US$50 (Type B). For more info (click here)
Velcro Strap

US$___________
Donation
(to the work of the Foundation)		 US$___________
Postage Zimbabwe US$ 4
Please measure wrist size for emblem chain cm
Delivery (approx 3 - 4 weeks) Please email us for postage to rest of Africa.
Collect Ordinary Post Registered Post
     

Total Payment $

Annual Renewal Membership Fee US$ 10
Please forward cheques or money order for the total amount to
MedicAlert®, P.O.Box 689, Harare,
or complete credit card details below. Payment with order please.

Bank Details: Standard Chartered Bank, FCA Highlands Branch. Acc Name: MedicAlert Foundatiion of Zimbabwe.Sort code: 5156, Acc No.: 8740210049800.

Mastercard Visa Card Other Card No.
Expiry Date: Signature:

Application, Authorisation And Indemnity Form
I, (Print) hereby apply for registration with the Medicalert® Foundation of Zimbabwe and authorise any medical officer or hospital official to give such particulars of my medical problems to the Medicalert® Foundation of Zimbabwe as it may deem necessary for use in the course of its work. I agree that I will not hold the MedicAlert® Foundation of Zimbabwe, nor any other person acting on its behalf, liable for any matter whatsoever arising from or connected with the registration of my name and particulars and/or the issue to me of a MedicAlert® emblem. I understand that 12 months after my particulars have been computerised, this application form may be destroyed.
Date: Signature:
(above section to be completed by all applicants, and by Parent/Guardians in case of minors)
"Prevent Emergencies from becoming Tragedies"