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
   Silver infill
Price
Qty
  
Disc & Chain
US$ 15
Type A Complete
US$ 35
 
N/A
Type B Complete
US$ 60
   
Type c Complete
US$ 65
 
N/A
 
N/A
 
N/A
     
Gold infill 10ct
  Miscelleous
 
Type A Complete
US$ 160
 
N/A
Type B Complete
US$ 160
 
N/A
Type c Complete
US$ 200
 
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.: 8740210049800.

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