MedicAlert® is a registered trademark and service mark. A National Registered Charity 10686 3293 RR0001. 3 EASY WAYS TO ENROL Use code NMA13N and receive up to $20 in special offers with monthly payments. 1. ONLINE Visit medicalert.ca/save 2. BY PHONE Call 1.855.724.2499 3. BY MAIL Complete the attached form (front and back) and mail to: Canadian MedicAlert Foundation, 2005 Sheppard Ave. East, Suite 800, Toronto, ON M2J 5B4 F O U N D A T I O N THIS JEWELRY COULD SAVE YOUR LIFE. Don’t die of denial. You may think a medical emergency will never happen to you, but it can. Wear MedicAlert.
Transcript
MedicAlert® is a registered trademark and service mark. A National Registered Charity 10686 3293 RR0001.
3 easy ways to enrol
Use code NMA13N and receive up to $20
in special offers with monthly payments.
1. ONLINEVisit medicalert.ca/save
2. BY PHONECall 1.855.724.2499
3. BY MAILComplete the attached form
(front and back) and mail to:
Canadian MedicAlert Foundation,
2005 Sheppard Ave. East, Suite 800,
Toronto, ON M2J 5B4
Your membership protects you 24/7.
Here’s how:
membership benefits
When you’re overwhelmed or hurt, your
MedicAlert ID and membership give
paramedics the information they need to
save your life.
speaKs for you
24/7 protection
When your life is at risk, paramedics call
our 24/7 Emergency Hotline. We answer
in 5 seconds, speak in 140 languages and
provide your full medical record.
notifies family
Don’t face an emergency alone. Our 24/7
Emergency Hotline specialists immediately
alert your loved ones, and even follow up
with you.
Your condition might seem like no big
deal. But emergencies happen every day,
and you may be unable to tell paramedics
what they need to know. MedicAlert
membership is for:
are you at risK?
• diabetes
• asthma
• allergies
• heart conditions
• hypertension
• blood thinners
• Alzheimer’s
• memory loss
• seizures
• pacemaker
• COPD
• devices
MedicAlert is a registered charity, not a business. We’re trusted by over 1 million Canadians.
F O U N D A T I O N
this jewelry could save your life.Don’t die of denial. You may think a medical emergency
will never happen to you, but it can.
Wear MedicAlert.
Pa
ren
t/Gu
ard
ian
Info
rma
tion
If new
mem
ber is a m
ino
r or an
adu
lt in th
e care of a g
uard
ian, p
lease specify n
ame o
f paren
t/gu
ardian
respo
nsib
le for
keepin
g th
e mem
ber reco
rd u
p to
date. Paren
t or g
uard
ian sh
ou
ld b
e the first Perso
nal Em
ergen
cy con
tact.
Nam
e R
elation
ship
Ad
dress
City
Prov.
Postal C
od
e
Pho
ne ( ) A
lternate Tel. ( ) E-M
ail
Em
erg
en
cy M
ed
ical C
on
tacts
Physician
1 Sp
ecialty
Tel. ( )
ext. ❏ Is this the Referring Physician?
Physician
2
Specialty
Tel. ( )
ext.
Pe
rson
al E
me
rge
ncy
Co
nta
cts (fam
ily/frie
nd
s)
1. Nam
e
Relatio
nsh
ip
Ho
me Tel. ( )
A
lternate Tel. ( )
2. Nam
e
Relatio
nsh
ip
Ho
me Tel. ( )
A
lternate Tel. ( )
Me
dica
l Co
nd
ition
s Reco
gn
ized m
edical term
ino
log
y and
abb
reviation
s will b
e used
.
Eng
raving
lang
uag
e ❏ En
glish
❏ Fren
ch
Med
ical Co
nd
ition
s (inclu
de an
y majo
r surg
eries or m
edical p
roced
ures)
All C
urren
t Med
ication
s (all prescrip
tion
med
ication
s)
Allerg
ies/anap
hylaxis D
o yo
u u
se an ep
inep
hrin
e injecto
r? ❏ Y
es ❏ N
o
Imp
lants/D
evices (inclu
de a co
py o
f you
r imp
lant card
if po
ssible)
TYPE M
AN
UFA
CTU
RER
MO
DEL N
O.
SERIA
L NO
.
Special N
eeds
Pe
rson
al In
form
atio
n
Are yo
u, o
r have yo
u ever b
een a M
edicA
lert mem
ber? ❏
No
❏ Y
es Med
icAlert ID
#
First Nam
e Last N
ame
❏ M
r. ❏ M
rs. ❏ M
s. ❏ D
r.
Co
mm
un
ication
s ❏ En
glish
❏ Fren
ch D
ate of B
irth (m
/d/y) / / G
end
er ❏ M
❏ F
Mailin
g A
dd
ress
A
pt.
City
Provin
ce/Territo
ry Po
stal Co
de
Best # to
con
tact ( ) Altern
ate Tel. ( ) ext.
Best tim
e to call: Em
ail ❏ N
ot availab
le
NM
A13
N
Req
uired
❏ I g
ive perm
ission
to th
e emerg
ency co
ntacts ab
ove to
access my m
edical in
form
ation
.
MedicAlert® is a registered trademark and service mark. A National Registered Charity 10686 3293 RR0001.
3 easy ways to enrol
Use code NMA13N and receive up to $20
in special offers with monthly payments.
1. ONLINEVisit medicalert.ca/save
2. BY PHONECall 1.855.724.2499
3. BY MAILComplete the attached form
(front and back) and mail to:
Canadian MedicAlert Foundation,
2005 Sheppard Ave. East, Suite 800,
Toronto, ON M2J 5B4
Your membership protects you 24/7.
Here’s how:
membership benefits
When you’re overwhelmed or hurt, your
MedicAlert ID and membership give
paramedics the information they need to
save your life.
speaKs for you
24/7 protection
When your life is at risk, paramedics call
our 24/7 Emergency Hotline. We answer
in 5 seconds, speak in 140 languages and
provide your full medical record.
notifies family
Don’t face an emergency alone. Our 24/7
Emergency Hotline specialists immediately
alert your loved ones, and even follow up
with you.
Your condition might seem like no big
deal. But emergencies happen every day,
and you may be unable to tell paramedics
what they need to know. MedicAlert
membership is for:
are you at risK?
• diabetes
• asthma
• allergies
• heart conditions
• hypertension
• blood thinners
• Alzheimer’s
• memory loss
• seizures
• pacemaker
• COPD
• devices
MedicAlert is a registered charity, not a business. We’re trusted by over 1 million Canadians.
F O U N D A T I O N
this jewelry could save your life.Don’t die of denial. You may think a medical emergency
will never happen to you, but it can.
Wear MedicAlert.
Pa
ren
t/Gu
ard
ian
Info
rma
tion
If new
mem
ber is a m
ino
r or an
adu
lt in th
e care of a g
uard
ian, p
lease specify n
ame o
f paren
t/gu
ardian
respo
nsib
le for
keepin
g th
e mem
ber reco
rd u
p to
date. Paren
t or g
uard
ian sh
ou
ld b
e the first Perso
nal Em
ergen
cy con
tact.
Nam
e R
elation
ship
Ad
dress
City
Prov.
Postal C
od
e
Pho
ne ( ) A
lternate Tel. ( ) E-M
ail
Em
erg
en
cy M
ed
ical C
on
tacts
Physician
1 Sp
ecialty
Tel. ( )
ext. ❏ Is this the Referring Physician?
Physician
2
Specialty
Tel. ( )
ext.
Pe
rson
al E
me
rge
ncy
Co
nta
cts (fam
ily/frie
nd
s)
1. Nam
e
Relatio
nsh
ip
Ho
me Tel. ( )
A
lternate Tel. ( )
2. Nam
e
Relatio
nsh
ip
Ho
me Tel. ( )
A
lternate Tel. ( )
Me
dica
l Co
nd
ition
s Reco
gn
ized m
edical term
ino
log
y and
abb
reviation
s will b
e used
.
Eng
raving
lang
uag
e ❏ En
glish
❏ Fren
ch
Med
ical Co
nd
ition
s (inclu
de an
y majo
r surg
eries or m
edical p
roced
ures)
All C
urren
t Med
ication
s (all prescrip
tion
med
ication
s)
Allerg
ies/anap
hylaxis D
o yo
u u
se an ep
inep
hrin
e injecto
r? ❏ Y
es ❏ N
o
Imp
lants/D
evices (inclu
de a co
py o
f you
r imp
lant card
if po
ssible)
TYPE M
AN
UFA
CTU
RER
MO
DEL N
O.
SERIA
L NO
.
Special N
eeds
Pe
rson
al In
form
atio
n
Are yo
u, o
r have yo
u ever b
een a M
edicA
lert mem
ber? ❏
No
❏ Y
es Med
icAlert ID
#
First Nam
e Last N
ame
❏ M
r. ❏ M
rs. ❏ M
s. ❏ D
r.
Co
mm
un
ication
s ❏ En
glish
❏ Fren
ch D
ate of B
irth (m
/d/y) / / G
end
er ❏ M
❏ F
Mailin
g A
dd
ress
A
pt.
City
Provin
ce/Territo
ry Po
stal Co
de
Best # to
con
tact ( ) Altern
ate Tel. ( ) ext.
Best tim
e to call: Em
ail ❏ N
ot availab
le
NM
A13
N
Req
uired
❏ I g
ive perm
ission
to th
e emerg
ency co
ntacts ab
ove to
access my m
edical in
form
ation
.
MedicAlert® is a registered trademark and service mark. A National Registered Charity 10686 3293 RR0001.
3 easy ways to enrol
Use code NMA13N and receive up to $20
in special offers with monthly payments.
1. ONLINEVisit medicalert.ca/save
2. BY PHONECall 1.855.724.2499
3. BY MAILComplete the attached form
(front and back) and mail to:
Canadian MedicAlert Foundation,
2005 Sheppard Ave. East, Suite 800,
Toronto, ON M2J 5B4
Your membership protects you 24/7.
Here’s how:
membership benefits
When you’re overwhelmed or hurt, your
MedicAlert ID and membership give
paramedics the information they need to
save your life.
speaKs for you
24/7 protection
When your life is at risk, paramedics call
our 24/7 Emergency Hotline. We answer
in 5 seconds, speak in 140 languages and
provide your full medical record.
notifies family
Don’t face an emergency alone. Our 24/7
Emergency Hotline specialists immediately
alert your loved ones, and even follow up
with you.
Your condition might seem like no big
deal. But emergencies happen every day,
and you may be unable to tell paramedics
what they need to know. MedicAlert
membership is for:
are you at risK?
• diabetes
• asthma
• allergies
• heart conditions
• hypertension
• blood thinners
• Alzheimer’s
• memory loss
• seizures
• pacemaker
• COPD
• devices
MedicAlert is a registered charity, not a business. We’re trusted by over 1 million Canadians.
F O U N D A T I O N
this jewelry could save your life.Don’t die of denial. You may think a medical emergency
will never happen to you, but it can.
Wear MedicAlert.
Pa
ren
t/Gu
ard
ian
Info
rma
tion
If new
mem
ber is a m
ino
r or an
adu
lt in th
e care of a g
uard
ian, p
lease specify n
ame o
f paren
t/gu
ardian
respo
nsib
le for
keepin
g th
e mem
ber reco
rd u
p to
date. Paren
t or g
uard
ian sh
ou
ld b
e the first Perso
nal Em
ergen
cy con
tact.
Nam
e R
elation
ship
Ad
dress
City
Prov.
Postal C
od
e
Pho
ne ( ) A
lternate Tel. ( ) E-M
ail
Em
erg
en
cy M
ed
ical C
on
tacts
Physician
1 Sp
ecialty
Tel. ( )
ext. ❏ Is this the Referring Physician?
Physician
2
Specialty
Tel. ( )
ext.
Pe
rson
al E
me
rge
ncy
Co
nta
cts (fam
ily/frie
nd
s)
1. Nam
e
Relatio
nsh
ip
Ho
me Tel. ( )
A
lternate Tel. ( )
2. Nam
e
Relatio
nsh
ip
Ho
me Tel. ( )
A
lternate Tel. ( )
Me
dica
l Co
nd
ition
s Reco
gn
ized m
edical term
ino
log
y and
abb
reviation
s will b
e used
.
Eng
raving
lang
uag
e ❏ En
glish
❏ Fren
ch
Med
ical Co
nd
ition
s (inclu
de an
y majo
r surg
eries or m
edical p
roced
ures)
All C
urren
t Med
ication
s (all prescrip
tion
med
ication
s)
Allerg
ies/anap
hylaxis D
o yo
u u
se an ep
inep
hrin
e injecto
r? ❏ Y
es ❏ N
o
Imp
lants/D
evices (inclu
de a co
py o
f you
r imp
lant card
if po
ssible)
TYPE M
AN
UFA
CTU
RER
MO
DEL N
O.
SERIA
L NO
.
Special N
eeds
Pe
rson
al In
form
atio
n
Are yo
u, o
r have yo
u ever b
een a M
edicA
lert mem
ber? ❏
No
❏ Y
es Med
icAlert ID
#
First Nam
e Last N
ame
❏ M
r. ❏ M
rs. ❏ M
s. ❏ D
r.
Co
mm
un
ication
s ❏ En
glish
❏ Fren
ch D
ate of B
irth (m
/d/y) / / G
end
er ❏ M
❏ F
Mailin
g A
dd
ress
A
pt.
City
Provin
ce/Territo
ry Po
stal Co
de
Best # to
con
tact ( ) Altern
ate Tel. ( ) ext.
Best tim
e to call: Em
ail ❏ N
ot availab
le
NM
A13
N
Req
uired
❏ I g
ive perm
ission
to th
e emerg
ency co
ntacts ab
ove to
access my m
edical in
form
ation
.
SR
ON
KJ
IHGF
EDC
Use a cloth ruler or the one provided to measure your wrist comfortably in inches. When measurement is ¼ inch size, order the next ½ inch size up.
Use the chart below to find your size.
Our Roots cuffs, Roots watches, and Persona bracelets are one size fits all, and fit wrists from 5” to 7”.
Necklaces not suitable for children under the age of 10 and beaded products are not sold to children under the age of 3.
Roots Leather Cuff Slim Combo - White and Black with one Stainless Steel emblem #257 / $75
Persona Double Cream Leather Bracelet with Sterling Silver emblem#496 / $139
Sterling Silver Box Chain Necklace#498 / $109
Stainless Steel Dog Tag#106 / $39
London Dog Tag - Rubber with Sterling Silver emblem#444 / $99
Cream Rose Pearl* Bracelet with Sterling Silver emblem#428 / $89
Ebony Roxy* Bracelet with Sterling Silver emblem#429 / $149
In an emergency, you may be too helpless or hurt to speak. So who will give paramedics the information they need to save your life?
We will.
All prices are subject to change without notice.
Standard
bracelets
Wrist
size
Expansion
bands
Beaded
bracelets
Bicycle
chains
5”
5 ½”
6”
6 ½”
7”
7 ½”
8”
8 ½”
9”
5”
5 ½”
6”
6 ½”
7”
7 ½”
8”
8 ½”
9”
6 S
S
7 M
ML
L
8
D
Persona Inspiring Style is a trademark of Personal Limited®ROOTS is a registered trade-mark of Roots Canada Ltd.
✃
AB
, Y
T,
NT
, N
U
ON
, N
B,
NF
NS
B
C,
MB
SK
QC
P
EI
5.0
0%
13
.00
%
1
5.0
0%
12
.00
%
10.0
0%
14.9
75
%
14
.00
%S
ale
s T
ax
(Lin
e D
x p
rov.
ta
x fr
om
ch
art
on
le
ft)
Re
gis
trat
ion
Fe
e(O
ne
tim
e f
ee
fo
r in
itia
l m
ed
ica
l re
cord
se
t u
p)
Tax
able
Am
ou
nt
(ad
d l
ine
s A
, B
& C
)
$8
.99
$2
4.0
0
Sh
ipp
ing
& H
and
lin
g
To
tal
(ad
d l
ine
s F,
G &
H)
Su
bto
tal
(ad
d l
ine
s D
& E
)
Me
mb
ers
hip
Fe
e
Pro
du
ct C
od
e #
Pro
du
ct N
ame
Pro
duc
t Si
zeP
rice
ME
TH
OD
OF
PA
YM
EN
T
❒ C
heq
ue
❒ B
ank
Acc
ount
Deb
it
P
leas
e m
ake
cheq
ue p
ayab
le t
o C
anad
ian
Med
icA
lert
Fo
und
atio
n®
Nam
e as
it a
pp
ears
on
card
Si
gna
ture
Ord
er
Fo
rm
- s
had
ed
are
as m
ust
be
fill
ed
in
Mo
nthl
y =
$5*
;
15
mo
nths
= $
75;
24
mo
nths
= $
110;
36
mo
nths
= $
150
*Ava
ilabl
e w
ith
cred
it c
ard
and
debi
t pa
ymen
t on
ly.
GST
/HST
Reg
istr
atio
n #
1068
6 32
93
Q
ST R
eg. #
1022
7070
74
Nat
iona
l Reg
iste
red
Char
ity
# 10
686
3293
RR0
001
*I g
ive
per
mis
sio
n to
cha
rge
my
cred
it c
ard
or
deb
it m
y b
ank
acco
unt
mo
nthl
y to
kee
p m
e p
rote
cted
.
A B C D E F G H
1. C
hoo
se a
sty
le f
rom
thi
s b
roch
ure
or
visi
t m
edic
aler
t.ca
/sav
e to
see
mo
re
2. M
easu
re y
our
wri
st s
ize
if o
rder
ing
a b
race
let
or
wat
ch3.
Pla
ce t
he p
rod
uct
cod
e, p
rod
uct
nam
e, p
refe
rred
siz
e (s
izin
g in
form
atio
n o
n p
rod
uct
pag
e) a
nd p
rice
in t
he a
pp
rop
riat
e co
lum
ns4.
Fill
out
the
ord
er f
orm
as
dir
ecte
d (c
om
bin
ed p
rovi
ncia
l tax
, mem
ber
ship
, pay
men
t o
pti
on)
5. M
ail c
om
ple
ted
ord
er f
orm
to
: Can
adia
n M
edic
Ale
rt F
oun
dat
ion,
200
5 Sh
epp
ard
Ave
. E.,
Suit
e 80
0, T
oro
nto
ON
M2J
5B
4
If y
ou
req
uire
ass
ista
nce,
ple
ase
cont
act
us a
t 1.
855.
724.
2499
COMPLIMENTARY RULER. Measure your wrist size and refer to complete sizing information on opposite page.
Pric
es a
re s
ubje
ct t
o ch
ange
wit
hout
not
ice.
Met
ho
d E
M
T
D❏
❏❏
❏
❏❏
❏❏
❏❏
❏❏
❏❏
❏❏
❏❏
❏❏
❏❏
❏❏
❏❏
❏❏
I aut
hori
ze C
anad
ian
Med
icA
lert
Fo
und
atio
n to
deb
it m
y b
ank
acco
unt
for
mem
ber
ship
pay
men
ts a
nd f
ees
(vo
id c
heq
ue e
nclo
sed
).
Co
nse
nt:
By
bec
om
ing
a m
emb
er, p
urc
has
ing
an
d w
eari
ng
an
y em
ble
m o
r p
rod
uct
id
enti
fyin
g y
ou
as
a M
edic
Ale
rt m
emb
er, y
ou
will
be
agre
ein
g t
o t
he
arra
ng
emen
t su
mm
ariz
ed b
elo
w a
nd
des
crib
ed in
th
e M
edic
Ale
rt M
emb
er S
tate
men
t th
at y
ou
may
o
bta
in o
n o
ur
web
site
(M
edic
aler
t.ca
) o
r b
y ca
llin
g (
1.85
5.72
4.24
99).
YO
U M
UST
REA
D
THE
MEM
BER
STA
TEM
ENT
BEF
OR
E A
PPLY
ING
FO
R M
EDIC
ALE
RT
MEM
BER
SHIP
BEC
AU
SE IT
D
ESC
RIB
ES T
HE
CH
OIC
ES Y
OU
HA
VE
AB
OU
T M
EDIC
ALE
RT
PRO
GR
AM
S A
ND
SER
VIC
ES,
INFO
RM
ATI
ON
MED
ICA
LER
T PR
OV
IDES
TO
MEM
BER
S, A
ND
OTH
ER IM
POR
TAN
T M
ATT
ERS
AFF
ECTI
NG
YO
UR
PR
IVA
CY
AN
D S
AFE
TY.
Plea
se c
all u
s if
yo
u w
ou
ld li
ke a
n e
xpla
nat
ion
o
r to
dis
cuss
th
e M
emb
er S
tate
men
t.
Wh
en y
ou
bec
om
e a
mem
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, Med
icA
lert
will
cre
ate
an e
lect
ron
ic �
le u
nd
er y
ou
r n
ame,
w
hic
h w
ill b
e ke
pt
at M
edic
Ale
rt in
To
ron
to, a
nd
will
ho
ld a
ll o
f th
e in
form
atio
n a
bo
ut
you
an
d y
ou
r h
ealt
h t
hat
we
rece
ive
fro
m y
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an
d/o
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ther
s. M
edic
Ale
rt w
ill p
rovi
de
you
w
ith
a c
ust
om
ized
Med
icA
lert
ID, i
ts 2
4-h
r h
otl
ine
(em
erg
ency
) se
rvic
e an
d in
form
atio
n.
Med
icA
lert
will
dis
clo
se in
form
atio
n in
yo
ur
�le
to
em
erg
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per
son
nel
an
d o
ther
s,
incl
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ing
Med
icA
lert
op
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ors
in t
he
U.S
.A.,
to p
rovi
de
you
wit
h t
he
ho
tlin
e se
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e.
Med
icA
lert
may
sh
are
and
rec
eive
per
son
al in
form
atio
n a
bo
ut
you
at
any
tim
e fr
om
an
yon
e yo
u n
ame
as a
co
nta
ct, u
nle
ss y
ou
sp
ecif
y o
ther
wis
e.
If y
ou
par
tici
pat
e in
th
e M
edic
Ale
rt S
afel
y H
om
e Pr
og
ram
, Med
icA
lert
will
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o p
rovi
de
som
e o
f th
e in
form
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yo
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�le
to
th
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lzh
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oci
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of
Can
ada
and
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cal
Alz
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So
ciet
y ch
apte
r fo
r p
urp
ose
s d
escr
ibed
in t
he
Mem
ber
Sta
tem
ent.
Y
ou
will
al
so r
ecei
ve in
form
atio
n a
bo
ut
ho
w t
he
wo
rk o
f th
e A
lzh
eim
er S
oci
ety
in C
anad
a is
fu
nd
ed, u
nle
ss y
ou
dec
line
bel
ow
. Y
ou
may
rev
iew
yo
ur
�le
on
line
or
by
calli
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us.
Yo
u a
re r
esp
on
sib
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hat
th
e in
form
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yo
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�le
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ect.
Med
icA
lert
will
no
t b
e re
spo
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ble
fo
r an
y h
arm
ca
use
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ecau
se t
he
info
rmat
ion
in y
ou
r �
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inco
mp
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or
inac
cura
te. Y
ou
will
be
req
uir
ed t
o p
ay m
emb
er f
ees.
Yo
u o
r M
edic
Ale
rt m
ay c
ance
l yo
ur
mem
ber
ship
by
follo
win
g t
he
Med
icA
lert
Can
cela
tio
n P
roce
ss -
Yo
u w
ill n
ot
rece
ive
any
Med
icA
lert
se
rvic
es a
nd
will
be
req
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ed t
o s
top
wea
rin
g y
ou
r M
edic
Ale
rt ID
as
soo
n a
s yo
u s
top
b
ein
g a
mem
ber
.
Yo
u w
ill r
ecei
ve s
pec
ial p
rom
oti
on
s an
d in
fo o
n t
hir
d p
arty
pro
gra
ms
that
may
be
of
inte
rest
to
yo
u, u
nle
ss y
ou
dec
line
bel
ow
.
Co
mm
un
icati
on
Emai
l (E)
; Mai
l (M
); M
ob
ile/T
ext
(T);
Do
No
t Se
nd
(D
)A
llN
ewsl
ette
rs &
mem
ber
sto
ries
Med
icA
lert
pro
du
ct n
ews
Med
icA
lert
off
ers
& p
rom
oti
on
s3r
d p
arty
par
tner
off
ers
Info
rmat
ion
ab
ou
t ch
arit
able
wo
rk•
Med
icA
lert
• A
lzh
eim
er S
oci
ety
Yo
u A
CK
NO
WLE
DG
E an
d a
gre
e th
at y
ou
hav
e re
ad a
nd
un
der
sto
od
th
e M
edic
Ale
rt
Mem
ber
Sta
tem
ent
avai
lab
le o
nlin
e at
ww
w.m
edic
aler
t.ca
or
by
calli
ng
1.8
55.7
24.2
499.
If y
ou
are
no
t th
e ap
plic
ant,
yo
u h
ave
the
per
mis
sio
n o
f th
e ap
plic
ant
or
a le
gal
rig
ht
to
com
ple
te t
his
fo
rm o
n b
ehal
f o
f th
e ap
plic
ant.
Sig
nat
ure
Dat
e
Nam
e (p
rin
t)
Pho
ne
nu
mb
er
Rel
atio
nsh
ip t
o m
emb
er
Ens
ure
you
read
and
sig
n th
e m
emb
er s
tate
men
t b
elo
w
Cre
dit
Car
d #
Exp
iry
Dat
e (m
/y)
/
//
/❒
VIS
A❒
Mas
terC
ard
❒ A
mer
ican
Exp
ress
Me
dic
Ale
rt®
is a
re
gis
tere
d t
rad
em
ark
an
d s
erv
ice
ma
rk.
A N
ati
on
al R
eg
iste
red
Ch
ari
ty 1
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86
32
93
RR
00
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3 e
as
y
wa
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t
o
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se c
od
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MA
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an
d r
ece
ive
up
to
$2
0
in s
pe
cia
l off
ers
wit
h m
on
thly
pa
ym
en
ts.
1. O
NLI
NE
Vis
it m
ed
ica
lert
.ca
/sa
ve
2. B
Y P
HO
NE
Ca
ll 1.
85
5.7
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3. B
Y M
AIL
Co
mp
lete
th
e a
tta
ch
ed
fo
rm
(fro
nt
an
d b
ack) a
nd
mail
to:
Ca
na
dia
n M
ed
icA
lert
Fo
un
da
tio
n,
20
05
Sh
ep
pa
rd A
ve
. E
ast
, S
uit
e 8
00
,
To
ron
to, O
N M
2J
5B
4
Yo
ur
me
mb
ers
hip
pro
tects
yo
u 2
4/7
.
He
re’s
ho
w:
me
mb
er
sh
ip
be
ne
fit
s
Wh
en
yo
u’r
e o
verw
he
lme
d o
r h
urt
, yo
ur
Me
dic
Ale
rt ID
an
d m
em
be
rsh
ip g
ive
pa
ram
ed
ics
the
info
rma
tio
n t
he
y n
ee
d t
o
save
yo
ur
life
.
sp
ea
Ks
fo
r y
ou
24
/7 p
ro
te
ct
ion
Wh
en
yo
ur
life
is a
t ri
sk, p
ara
me
dic
s ca
ll
ou
r 2
4/7
Em
erg
en
cy
Ho
tlin
e. W
e a
nsw
er
in 5
se
co
nd
s, s
pe
ak in
14
0 la
ng
ua
ge
s a
nd
pro
vid
e y
ou
r fu
ll m
ed
ica
l re
co
rd.
no
tif
ies
fa
mil
y
Do
n’t
fa
ce
an
em
erg
en
cy
alo
ne
. Ou
r 2
4/7
Em
erg
en
cy
Ho
tlin
e s
pe
cia
lists
imm
ed
iate
ly
ale
rt y
ou
r lo
ved
on
es,
an
d e
ven
fo
llow
up
wit
h y
ou
.
Yo
ur
con
ditio
n m
igh
t se
em
like
no
big
de
al.
Bu
t e
me
rge
nci
es
ha
pp
en
eve
ry d
ay,
an
d y
ou
ma
y b
e u
na
ble
to
te
ll p
ara
me
dic
s
wh
at
the
y n
ee
d t
o k
no
w. M
ed
icA
lert
me
mb
ers
hip
is f
or:
ar
e y
ou
a
t r
isK
?
• d
iab
ete
s
• a
sth
ma
• a
lle
rgie
s
• h
ea
rt c
on
dit
ion
s
• h
yp
ert
en
sio
n
• b
loo
d t
hin
ne
rs
• A
lzh
eim
er’
s
• m
em
ory
lo
ss
• se
izu
res
• p
ace
ma
ke
r
• C
OP
D
• d
evic
es
Me
dic
Ale
rt i
s a
re
gis
tere
d c
ha
rity
, n
ot
a b
usi
ne
ss.
We
’re
tru
ste
d b
y o
ve
r 1
mil
lio
n C
an
ad
ian
s.
FO
UN
DA
TI
ON
th
is
jew
el
ry
c
ou
ld
s
av
e
yo
ur
l
ife
.D
on
’t d
ie o
f d
en
ial.
Yo
u m
ay
thin
k a
me
dic
al e
me
rge
ncy
will
ne
ver
ha
pp
en
to
yo
u, b
ut
it c
an
.
We
ar
Me
dic
Ale
rt.
Parent/Guardian Information
If new member is a minor or an adult in the care of a guardian, please specify name of parent/guardian responsible for keeping the member record up to date. Parent or guardian should be the first Personal Emergency contact.
Name Relationship
Address City Prov. Postal Code
Phone ( ) Alternate Tel. ( ) E-Mail
Emergency Medical Contacts
Physician 1 Specialty
Tel. ( ) ext. ❏ Is this the Referring Physician?
Physician 2 Specialty
Tel. ( ) ext.
Personal Emergency Contacts (family/friends)
1. Name Relationship
Home Tel. ( ) Alternate Tel. ( )
2. Name Relationship
Home Tel. ( ) Alternate Tel. ( )
Medical Conditions Recognized medical terminology and abbreviations will be used.
Engraving language ❏ English ❏ French
Medical Conditions (include any major surgeries or medical procedures)
All Current Medications (all prescription medications)
Allergies/anaphylaxis Do you use an epinephrine injector? ❏ Yes ❏ No
Implants/Devices (include a copy of your implant card if possible)
TYPE MANUFACTURER
MODEL NO. SERIAL NO.
Special Needs
Personal Information
Are you, or have you ever been a MedicAlert member? ❏ No ❏ Yes MedicAlert ID#
First Name Last Name ❏ Mr. ❏ Mrs. ❏ Ms. ❏ Dr.
Communications ❏ English ❏ French Date of Birth (m/d/y) / / Gender ❏ M ❏ F
Mailing Address Apt.
City Province/Territory Postal Code
Best # to contact ( ) Alternate Tel. ( ) ext.
Best time to call: Email ❏ Not available
NMA13N
Required
❏ I give permission to the emergency contacts above to access my medical information.
SR
ON
KJ
IH
GF
ED
C
Use
a clo
th ru
ler o
r the
on
e p
rovid
ed
to m
ea
sure
you
r wrist co
mfo
rtab
ly in
inch
es. W
he
n m
ea
sure
me
nt is ¼
inch
size, o
rde
r the
ne
xt ½ in
ch size
up
.
Use
the
cha
rt be
low
to fi
nd
you
r size.
Ou
r Ro
ots cu
ffs, R
oo
ts wa
tche
s, an
d P
erso
na
bra
cele
ts are
on
e size
fits a
ll, a
nd
fit w
rists from
5” to
7”.
Ne
ckla
ces n
ot su
itab
le fo
r child
ren
un
de
r the
ag
e o
f 10 a
nd
be
ad
ed
p
rod
ucts a
re n
ot so
ld to
child
ren
un
de
r the
ag
e o
f 3.
Ro
ots Le
ath
er C
uff
Slim
C
om
bo
- Wh
ite a
nd
Bla
ck w
ith
on
e S
tain
less S
tee
l em
ble
m
#2
57
/ $7
5
Pe
rson
a D
ou
ble
Cre
am
Le
ath
er B
race
let w
ith
Ste
rling
Silve
r em
ble
m#
49
6 / $
139
Ste
rling
Silve
r Bo
x C
ha
in N
eck
lace
#4
98
/ $10
9
Sta
inle
ss Ste
el D
og
Ta
g#
106
/ $3
9
Lon
do
n D
og
Ta
g - R
ub
be
r w
ith S
terlin
g S
ilver e
mb
lem
#4
44
/ $9
9
Cre
am
Ro
se P
ea
rl* Bra
cele
t w
ith S
terlin
g S
ilver e
mb
lem
#4
28
/ $8
9
Eb
on
y Ro
xy* Bra
cele
t with
S
terlin
g S
ilver e
mb
lem
#4
29
/ $14
9
Am
eth
yst* Sta
inle
ss S
tee
l Bra
cele
t#
24
7 / $
75
Vin
tag
e P
latin
um
P
ea
rl* Bra
cele
t with
S
terlin
g S
ilver e
mb
lem
#
43
1 / $9
9
Ch
else
a S
terlin
g
Silve
r Bra
cele
t#
42
3 / $
199
SIz
ING
INF
OR
MA
TIO
N
CH
OO
SE
YO
UR
ST
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:A
LNOPQRSTU
BCEFGHIJ
MA
B
LM
PQ
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* With
SW
AR
OV
SK
I EL
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EN
TS
.
Infin
ity Links S
terlin
g
Silve
r Bra
cele
t#
48
7 / $
24
9
Fig
aro
Ste
rling
Silve
r Bra
cele
t#
40
9 / $
99
Mila
no
Ste
rling
S
ilver B
race
let
#4
11 / $19
9
De
sign
er S
ilver
Exp
an
sion
Bra
cele
t #
40
6 / $
119
Bicycle
Ch
ain
Bra
cele
t w
ith S
tee
l Links
#2
69
/ $8
0
Bla
ck S
po
rt Ba
nd
with
S
tain
less S
tee
l em
ble
m#
20
9 / $
40
Ro
ots M
en
’s Wa
tch w
ith
Sta
inle
ss Ste
el e
mb
lem
#2
50
/ $9
9
Ste
rling
Silve
r Bra
cele
t#
40
0 / $
99
Sp
ecia
l Go
ld B
race
let -
Go
ld-fi
lled
cha
in - 10
K g
old
e
mb
lem
#6
00
/ $4
49
De
sign
er S
tain
less
Ste
el B
race
let
#10
3 / $
39
Ste
rling
Silve
r U
nive
rsal C
ha
rm#
43
8 / $
80
K
Mo
re sty
les a
t me
dica
lert.ca
/save
Fe
atu
ring
:
In a
n e
me
rge
ncy, yo
u
ma
y be
too
he
lple
ss or
hu
rt to sp
ea
k. S
o w
ho
w
ill give
pa
ram
ed
ics th
e in
form
atio
n th
ey
ne
ed
to sa
ve yo
ur life
?
We
will.
All p
rices a
re su
bje
ct to
cha
ng
e w
itho
ut n
otice
.
Sta
nd
ard
bra
cele
ts
Wrist
size
Exp
an
sion
ba
nd
s
Be
ad
ed
bra
cele
ts
Bicycle
cha
ins
5”
5 ½
”
6”
6 ½
”
7”
7 ½
”
8”
8 ½
”
9”
5”
5 ½
”
6”
6 ½
”
7”
7 ½
”
8”
8 ½
”
9”
6S
S
7M
ML
L
8
D
Pe
rson
a In
spirin
g S
tyle is a
trad
em
ark
of P
erso
na
l Limite
d®R
OO
TS
is a re
giste
red
trad
e-m
ark
of R
oo
ts Ca
na
da
Ltd.
✃
AB, YT, NT, NU ON, NB, NF NS BC, MB SK QC PEI 5.00% 13.00% 15.00% 12.00% 10.00% 14.975% 14.00%
Sales Tax (Line D x prov. tax from chart on left)
Registration Fee(One time fee for initial medical record set up)
Taxable Amount (add lines A, B & C)
$8.99
$24.00
Shipping & Handling
Total (add lines F, G & H)
Subtotal (add lines D & E)
Membership Fee
Product Code # Product Name Product Size Price
METHOD OF PAYMENT
❒ Cheque
❒ Bank Account Debit
Please make cheque payable to Canadian MedicAlert Foundation®
*Available with credit card and debit payment only.GST/HST Registration # 10686 3293 QST Reg. #1022707074
National Registered Charity # 10686 3293 RR0001
*I give permission to charge my credit card or debit my bank account monthly to keep me protected.
A
B
C
D
E
F
G
H
1. Choose a style from this brochure or visit medicalert.ca/save to see more 2. Measure your wrist size if ordering a bracelet or watch3. Place the product code, product name, preferred size (sizing information on product page) and price in the appropriate columns4. Fill out the order form as directed (combined provincial tax, membership, payment option)5. Mail completed order form to: Canadian MedicAlert Foundation, 2005 Sheppard Ave. E., Suite 800, Toronto ON M2J 5B4 If you require assistance, please contact us at 1.855.724.2499
CO
MP
LIME
NTA
RY
RU
LER
. Measure yo
ur wrist size and
refer to co
mp
lete sizing info
rmatio
n on o
pp
osite p
age.
Prices are subject to change without notice.
Method E M
T D❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
❏ ❏ ❏ ❏
I authorize Canadian MedicAlert Foundation to debit my bank account for membership payments and fees (void cheque enclosed).
Consent: By becoming a member, purchasing and wearing any emblem or product identifying you as a MedicAlert member, you will be agreeing to the arrangement summarized below and described in the MedicAlert Member Statement that you may obtain on our website (Medicalert.ca) or by calling (1.855.724.2499). YOU MUST READ THE MEMBER STATEMENT BEFORE APPLYING FOR MEDICALERT MEMBERSHIP BECAUSE IT DESCRIBES THE CHOICES YOU HAVE ABOUT MEDICALERT PROGRAMS AND SERVICES, INFORMATION MEDICALERT PROVIDES TO MEMBERS, AND OTHER IMPORTANT MATTERS AFFECTING YOUR PRIVACY AND SAFETY. Please call us if you would like an explanation or to discuss the Member Statement. When you become a member, MedicAlert will create an electronic �le under your name, which will be kept at MedicAlert in Toronto, and will hold all of the information about you and your health that we receive from you and/or others. MedicAlert will provide you with a customized MedicAlert ID, its 24-hr hotline (emergency) service and information. MedicAlert will disclose information in your �le to emergency personnel and others, including MedicAlert operators in the U.S.A., to provide you with the hotline service. MedicAlert may share and receive personal information about you at any time from anyone you name as a contact, unless you specify otherwise. If you participate in the MedicAlert Safely Home Program, MedicAlert will also provide some of the information in your �le to the Alzheimer Society of Canada and the local Alzheimer Society chapter for purposes described in the Member Statement. You will also receive information about how the work of the Alzheimer Society in Canada is funded, unless you decline below. You may review your �le online or by calling us. You are responsible for making sure that the information in your �le is correct. MedicAlert will not be responsible for any harm caused because the information in your �le is incomplete or inaccurate. You will be required to pay member fees. You or MedicAlert may cancel your membership by following the MedicAlert Cancelation Process - You will not receive any MedicAlert services and will be required to stop wearing your MedicAlert ID as soon as you stop being a member.
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