Thank you for selecting
Medical Information Card!
Contact us with any questions at info@emednet.org
 
Step 1.   Please fill out form completely. 
Step 2.  Verify that your information is correct. 
Step 3.  Click Submit  
Once you submit your information you will be directed to PayPal for your secure payment.

Last Name (required)
 First Name (required)
 Middle Name
 Social Security # (optional)
Street Address (required)
 City (required)
 State (required)   
 Zip (required)
 
Date of Birth  (dd/mm/yr)
   

Gender
   

  Height
 ft.in

Weight     

 Eyes
    Hair   Phone Number
Religion (optional)
  		 Blood Type (if known)
 		 Blood Pressure
/
Occupation
 Employers Name
 Phone Number
Medical Insurance Company
 Policy Number
 Group #
Medial Insurance Company
 Policy Number
 Group #
Hospital Preference
 Drivers License #
  
Do you wear dentures?YesNo      Glasses? YesNo Hearing aid?   YesNo Contact lenses?  YesNo
Veteran?   YesNoData Discharged? Service #

Pets at home?  YesNo
Contact for pet care:

                EMERGENCY CONTACTS:

    
Name
 Phone Number    
     		 Physician Name
 Phone Number
Name
 Phone Number    
     		 Physician Name
 Phone Number
Name
 Phone Number    
     		 Physician Name
 Phone Number  
Do you want to be placed on Life Support?        YES       NO
          ALLERGIES  Yes   No

                        EXISTING MEDICAL CONDITIONS  YES    NO

Anesthetics
 (list)		 AIDS

Implanted Pace-Maker 

Asthma Missing Organ 
Antibiotics 
(list) 		Orthopedic Implants Respiratory Problems 
Cancer Kidney Disease 
Aspirin IVP dyes   Chemotherapy Sickle Cell Disease 
Codeine Morphine Diabetes Stroke
Demerol Tetanus Emphysema Tuberculosis
Insect stings Food Types Epilepsy Ulcer
Food Coloring Other(list)                        Glaucoma Hemophilia

  

 
Hepatitis

      Other (list here) 
                    

High Blood Pressure

ON-GOING  PRESCRIPTIONS YesNo     Please enter The drug name and dosage below.
Drug

Dosage
 

Drug

Dosage

Drug

Dosage

Drug

Dosage

Drug

Dosage

 Drug

Dosage


Drug

Dosage

Drug

Dosage

Drug

Dosage

Drug

Dosage

    Drug
  
   Dosage
  

   Drug
  
   Dosage
  

   Drug
  
   Dosage
  

   Drug
  
   Dosage
  

   Drug
  
   Dosage
  

 
HEALTH CARE DIRECTIVE?
Yes No 		Where on File?
 Contact:

 Phone #

Last Hospitalization: (include date)

 Illness
 		Doctor:
Last Surgery (include date)
 Illness
 		Doctor:
Do you Currently Smoke?
Yes No 		Have you ever smoked?
Yes No 		Number of years smoked?     
Number of pack per day?       

UNIFORM TISSUE/
ORGAN DONOR AUTHORIZATION

I hereby voluntarily make this gift to take effect upon my death: Yes No (required)
 

Any Organ
Specific Organ


I hereby forego my signature and agree that all of the information is true to the best of my knowledge.
Yes    No (required)

 

You Must "Submit Your Info" to complete your transaction