Diann Shaddox Foundation for Essential Tremor

DSF ET MEDICAL ALERT CARD & ENVELOPE

MEDICAL ALERT wallet sized PICTURE CARD &
Medical Alert envelope with picture for your vehicle

No cost.
Fill out information below.

United States -We will be glad to fill out & mail your card & envelope

Outside of the United States. We will be glad to fill out your card & email your card for you to print.

Information medical Cards/envelopes to help communicate information regarding your medical history, allergies, medications, emergency contacts, and doctor(s).

We are glad to help you fill out your card.
Fill out form below!

ET Medical Alert Card & ENVELOPE Form

Give a few weeks to receive your Medical Alert Card in the mail
The Diann Shaddox Foundation does not retain or use your medical information in any way.

* Indicates required field

Name on Medical Alert Card *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Choose which Medical Alert Card-envelope you would like. *

* Medical Alert Card & envelope without a photo * Medical Alert Card & envelope with photo uploadl below

Add your information Below

Emergency Contact Name & Number *

Physician Name & Number *

List of other Medical conditions & allergies *

Upload photo for Medical Alert Card & Envelope Optional *

Max file size: 20MB

I agree to receiving marketing and promotional materials

Submit

You may also Print your wallet size card.
Simply download, print, & fill out card, cut the card, laminae, & fold in half.

If you would like to print your own Medical Alert card or Envelope download here

medical_alert_without_picture_packet.pdf
File Size:	45 kb
File Type:	pdf

Download File

medical_alert_envelope.pdf
File Size:	359 kb
File Type:	pdf

Download File

MEDICAL ENVELOPE FOR VEHICLE TO KEEP YOUR INSURANCE & REGISTRATION