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MedicAlert Enrollment Form

English
For bracelet sizing measure the circumference of your wrist and add 1/2 inch.
*Engraving text may be changed to fit item character limits
(Person who will wear the ID)
Address
(Primary Caregiver)

Terms & Conditions

MedicAlert + Alzheimer's Association Safe Return, Found and Caregiver Services
By purchasing medical identification product(s) and/or enrolling in related service from MedicAlert Foundation, for yourself as member or caregiver and/or as caregiver on behalf of the member named above (collectively, "you"), you authorize MedicAlert Foundation to release all medical and other confidential information about you in emergencies and to other healthcare personnel you designate. The member (or caregiver) is authorizing MedicAlert to share medical and confidential information with United Healthcare. MedicAlert Foundation relies upon the accuracy of the information that you provide. You, therefore, agree to defend, indemnify, and hold MedicAlert Foundation (including its employees, officers, directors, agents, and organizations with which it maintains a marketing alliance for the provision of services hereunder) harmless from any claim or lawsuit brought by member or others for injury, death, loss or damages arising in whole or in part out of your provision of incomplete or inaccurate information to MedicAlert Foundation. Furthermore, as caregiver for the member named above, you hereby represent and warrant to MedicAlert Foundation that you have full power and authority, as the duly authorized representative of such member, to enroll and act on his or her behalf.
with the Terms of Service (type your initials in the text box to agree).

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