Medical Alert Card Information Form

SARA, PO Box 607, Midlothian, TX. 76065

3 Medical Alert cards: $25.00 - each additional card $5.00 – Shipping & Handling $7.00 per order

Texas Residents must add 6.75% Texas Sales Tax

 

Full name:

 

Address:

 

City & State:

 

Date of Birth:

 

Emergency Contact 1:

 

Emergency Ph #:

 

Emergency Contact 2:

 

Emergency Ph #:

 

Primary Physician:

 

Physician Ph #:

 

Medical Info:

 

 

 

 

 

 

 

 

 

Prescribed Drugs:

 

 

 

 

 

Religion (if applicable):

 

DNR:

NO = resuscitate              YES = DNR            (circle)

Blood Products Allowed:

NO              YES            (circle)

Organ Donor:

NO               YES           (circle)