MedicAlert® Replacement Form
Current member
Registration No.
Date of Birth
Sex
Yes No
Male Female
Members Details  
Surname First Name              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:
Replacement Prices
Stainless Steel
Price
Qty
   S/Steel disc Colour S/Steel Chain Colour   Silver infill
Price
Qty
  
Disc & S/Steel Chain
US$ 15
    Type A Complete
US$ 80
Disc & Bead Chain
US$ 20
     Type B Complete
US$ 85
Raised Disc & S/Chain
US$ 20
      Type C Complete
US$ 95
Raised Disc & Bead Chain
US$ 20
     
N/A
 
N/A
     
Gold infill 10ct
        Miscelleous
 
Type A Complete
US$ 280
       
N/A
Type B Complete
US$ 230
       
N/A
Type c Complete
US$ 270
       
N/A
         
Please press calculate button for each section before calculating Total          
Donation
 To the work of the foundation
Please emailm us for postage to rest of Africa.          
Plus P&P
 Please add US$ 3 to your remittance for registered post. (Zimbabwe only)  
               
Info. update fee
                 
Total
Date: Signature:

 
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.: 8700210049800.

Mastercard Visa Card Other Card No.
Expiry Date: Signature:
"Prevent Emergencies from becoming Tragedies"