[Village of Glen Ellyn] MedicAlert

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MedicAlert Found- Autism (individuals with autism or developmental disorders)

MedicAlert + Alzheimer's Association Safe Return (individuals with Alzheimer's or dementia)

Personal Information

Home Phone

Cell Phone

Gender

Male

Female

Emergency Contact Information

Relationship

Emergency Contact's Phone

Primary Physician

Physician Phone

Medical Conditions/Allergies/Medications

Please list

No Known

Medical Conditions

Allergies

Medications

Engraving You Would Like

Engraving character limits vary. List most important items first.

Line 1

Line 2

Line 3

Line 4

Select Your Medical ID

Please select only one. If selecting a bracelet, please measure your wrist and add 1/2 inch.

Medical ID Options

Small Bracelet

Large Bracelet

Pendant

Wrist Size (if bracelet option was selected)

Chain Length (if pendant option was selected)

26 inches

30 inches

Customer Signature

First Name

Last Name

Choose how to sign

Draw Type

By signing above you agree to MedicAlert terms and conditions as shown online at www.medicalert.org/consent. A parent or guardian signature is required for members under 18.

Today's Date

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Personal Information

Full Name

Full Address

Date of Birth

Gender

Emergency Contact Information

Full Name

Medical Conditions/Allergies/Medications

No Known

Engraving You Would Like

Select Your Medical ID

Medical ID Options

Chain Length (if pendant option was selected)

Customer Signature

Today's Date