Medi ID printable version l AidMe Motor club benefits & roadside assistance benefits

AidMe Services www.aidme.net l 800-379-3840

Medical ID Card (Plastic durable card) Printable Application

Personal Information ALL INFORMATION IS VOLUNTARY Application Tracking is Your Name and Your Contact Number

What is the AidMe
Medical ID Card

A safe plastic card (credit card type)
that stores your contact information
medical history illnesses and allergies.

It can be placed on the refrigerator or
in your wallet and it's machine washable.
(Familiar places for first responders)

Why the AidMe
Medical ID Card

Family, friends and neighbors will be
able to provide the correct information
to first responders if you're incoherent
or passed out.

Now everyone can be safe whether at
a daycare center, school, or work place.
Away at a social gathering or on vacation.

EMS and emergency room personnel are
informed and can better attend to your
needs.

Who needs the AidMe
Medical ID Card

Everyone!

Kids put it around their neck, in their
pocket, book bag or in their shoe.

Motorist or pedestrians place it in their
wallet next to an identification card or
license.

_____________________ Date Card Completed:	Living Will: (Check one) Yes___ No___	Organ Donor: (Check one) Yes___ No___	___________________ Blood Type
_____________________ First Name	____________________ Last Name	____________________ Date of Birth	____________________ Your Contact Number
_____________________ Address	____________________ City/Town	____________________ State	____________________ Zip
_____________________ Whom to Contact	____________________ Contact's Number	____________________ Doctor's Name	____________________ Doctor's Number
Healthcare Plan Yes___ No___	Medicare Yes___ No___	Medicaid Yes___ No___	____________________ Other

1.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
2.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
3.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
4.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
5.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
6.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
7.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
8.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
9.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________
10.	Current Medication	Dosage Strength	How Often Taken	When Taken
	______________________________	______________	______________	___________

	Major Illnesses and Allergies
1.	_________________________________________________________________________
2.	_________________________________________________________________________
3.	_________________________________________________________________________
4.	_________________________________________________________________________
5.	_________________________________________________________________________

I agree that all responsibility for misinformation and filling of this form is solely that of my own.

__________________________________
Applicant Signature

Please Mail this Application To:
Aid Me Services l PO Box 704 l Egg Harbor City l NJ l 08215
Add a Check or Money Order in the Amount $9.99 for full year.
We can update your information at any time and it's free.

				Links
AidMe Services 2012 Corporate Office: J.E. Gandy Building l 200 Philadelphia Ave l Egg Harbor City l NJ l 08215