1. Medical ID and Emergency Contact Form; Revised 1-16-2022

PLEASE ALLOW UP TO 10 BUSINESS DAYS FOR REPLY TO THIS REQUEST

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* 1. First and Last Name of the person who will be wearing the ID bracelet tag.

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* 2. The person wearing this ID bracelet tag will be:

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* 3. Your First and Last Name. You are the person filling out this form on behalf of someone else OR yourself. Enter the word "Myself" below, if the ID bracelet tag is for you.

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* 4. Your Email.

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* 5. Your Organization/Business Name, if there is one.

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* 6. Your Relationship to the person using the ID kit, i.e., Caregiver, Care Partner, Spouse, Child, Sibling, Friend, Health Professional, Care Team, First-Responder, Agency/Community Representative, "Myself," etc.

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* 7. How did you learn about the ID kit? Please provide as much information as possible, i.e., person's name, business/organization, address, phone, email. Any additional info is helpful.

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* 8. Your shipping address. This address is where we will send the ID kit

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* 9. Your best contact phone number?

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* 10. Is this a mobile phone?

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* 11. Gender of Person using ID.

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* 12. Birthdate of Person using ID. USE MM/DD/YYYY AS FORMAT.

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* 13. Home Address of Person using ID.

EMERGENCY CONTACT -  Even if you are both the emergency contact and the person filling out this form - please complete the information box below too.

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* 14. MUST PROVIDE the first and last name of emergency contact, their best phone number, email, and their relationship to ID wearer.

WHAT DO WE ENGRAVE ON THE ID BRACELET TAG? Depending on your answer to question #2, COGNITIVE IMPAIRMENT or CAREGIVER will be engraved on every bracelet tag. You can have engraved ONE other vital medical condition or allergy below.

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* 15. OPTIONAL - one other important medical condition/allergy to be engraved on the bracelet tag, i.e., Type II Diabetes, Fall Risk, Latex Allergy, etc.

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* 16. Please confirm: I have read and accepted the Terms of Use and Privacy Statement from MyID.com (the supplier of the ID#, PIN, QR Code, wallet ID card, online profile, and other items):
https://www.getmyid.com/terms-of-use;
https://www.getmyid.com/privacy-policy

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* 17. PLEASE READ AND CONFIRM ACCEPTANCE: I understand that the Dementia Society, Inc. d/b/a Dementia Society of America, Care Network America, or Operation KeepSafe, and/or its assigns are providing the identification (ID) tags and related items, and online ID profile, as a distributor/reseller of the products/services from various suppliers, including MyID.com. I understand that the Dementia Society, Inc., and/or its assigns assume no responsibility for the operation, performance, or outcomes for any particular purpose from the use of said products/services. Failure of the products and/or services may result in delayed help, no help, bodily harm, and even death. The information in the online profile or engraved/printed on the ID products is only as good/current/valid as the data entered or provided. Dementia Society, Inc. and/or its assigns assume no responsibility for updating or maintaining the accuracy of any information provided/input. The Dementia Society of America and/or its assigns assume no responsibility for health information revealed to third parties. The user/caregiver/wearer is providing health information intended to be seen/viewed or otherwise recorded or stored for the purposes of communicating information, personally identifiable (ID) information, and/or medical conditions and data, to third parties, even persons unknown to the user/wear, et al, and possibly including the public. The user/caregiver/wearer assumes all responsibility to test and validate the products/services operation/data on a regular basis. These products/services are not guaranteed. At the sole discretion of Dementia Society, Inc., replacements for lost or broken products may be provided at no charge. No refunds are made for any products/services purchased/provided.

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* 18. Do you have any questions or comments?

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