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,

3 easy
ways
to
enrol

rs

oss

er

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

MedicAlert is a registered trademark and service mark.


A National Registered Charity 10686 3293 RR0001.

this
jewelry
could
save
your
life.
Dont die of denial.
You may think a medical emergency
will never happen to you, but it can.
Wear MedicAlert.

F O U N D A T I O N

membership
benefits

ar
at
Your membership protects you 24/7.
Heres how:

Your
deal.
and y
what
mem

First Name

Communications English French

Mailing Address

City

Best # to contact (

Best time to call:

Name

Address

Phone (

Physician 1
Tel. (
Physician 2

alle
he

blo

Personal Information

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.

Last Name
Date of Birth (m/d/y)

Province/Territory
Alternate Tel. (
Email

Required

Parent/Guardian Information

City
Alternate Tel. (

Med
We

Apt.

Not available

ext.

Postal Code

Gender M F

Mr. Mrs. Ms. Dr.

notifies family
Relationship

Postal Code

Is this the Referring Physician?

E-Mail

Prov.

Specialty

Emergency Medical Contacts


ext.
Specialty

More styles at medicalert.ca/save

ast

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.

We will.

Dont face an emergency alone. Our 24/7


Emergency Hotline specialists immediately
alert your loved ones, and even
follow up
R
S
with you.

P
O
N

L
K

hy

24/7 protection
J

dia
When youre overwhelmed or hurt, your
MedicAlert ID and membership give
paramedics the information they need to
save your life.

H
G
F

Are you, or have you ever been a MedicAlert member? No Yes MedicAlert ID#

speaKs for you

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?

CHO

Your membership protects you 24/7.


Heres how:

speaKs for you


F

Personal Information

Last Name

Are you, or have you ever been a MedicAlert member? No Yes MedicAlert ID#

First Name

membership
benefits

When youre overwhelmed or hurt, your


MedicAlert ID and membership give
paramedics the information they need to
save your life.

are you
at risK?

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:
H

diabetes

Alzheimers

asthma

memory loss

allergies

seizures

heart conditions pacemaker


J

24/7 protection
K

hypertension
blood thinners

COPD
devices

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.
N

3
w
t
e

A Roots
Comb
one S
#257

B Perso
Leath
Sterli
#496
C Sterli
Chain
#498
D
Stain
#106
E Lond
with S
#444
F Cream
with S
#428
G Ebon
Sterli
#429
H Amet
Steel
#247
I Vinta
Pearl
Sterli
#431

1.

2.

Chels
Silver
#423

* With S

SIz

3.

Use a clo
inches. W

Use the

Our Roo
and fit w

Mr. Mrs. Ms. Dr.

notifies family

Necklace
products

Wri
siz

Dont face an emergency alone. Our 24/7


Emergency Hotline specialists immediately
alert your loved ones, and
even follow up
S
with you.

U
MedicAlert is a registered charity, not a business.
Were trusted byFeaturing:
over 1 million Canadians. All prices are subject to

change without notice.

More styles at medicalert.ca/save

Persona Inspiring Style is a trademark of Personal Limited


ROOTS is a registered trade-mark of Roots Canada Ltd.

5
5
6
6
7
Me
7
A8N
8
9

A Roots Leather Cuff Slim


Combo - White and Black with
one Stainless Steel emblem
#257 / $75
C

K Infinity Links Sterling


Silver Bracelet
#487 / $249
L Figaro Sterling Silver Bracelet
#409 / $99
M Milano Sterling
Silver Bracelet
#411 / $199
N Designer Silver
Expansion Bracelet
#406 / $119
O Bicycle Chain Bracelet
with Steel Links
#269 / $80
P Black Sport Band with
Stainless Steel emblem
#209 / $40
Q Roots Mens Watch with
Stainless Steel emblem
#250 / $99
R Sterling Silver Bracelet
#400 / $99
S Special Gold Bracelet Gold-filled chain - 10K gold
emblem
#600 / $449
T Designer Stainless
Steel Bracelet
#103 / $39
U Sterling Silver
Universal Charm
#438 / $80

B Persona Double Cream


Leather Bracelet with
Sterling Silver emblem
#496 / $139
C Sterling Silver Box
Chain Necklace
#498 / $109
D
Stainless Steel Dog Tag
#106 / $39
E London Dog Tag - Rubber
with Sterling Silver emblem
#444 / $99
F Cream Rose Pearl* Bracelet
with Sterling Silver emblem
#428 / $89
G Ebony Roxy* Bracelet with
Sterling Silver emblem
#429 / $149
H Amethyst* Stainless
Steel Bracelet
#247 / $75
I Vintage Platinum
Pearl* Bracelet with
Sterling Silver emblem
#431 / $99
J

Chelsea Sterling
Silver Bracelet
#423 / $199
* With SWAROVSKI ELEMENTS.

SIzING INFORMATION
Use a cloth ruler or the one provided to measure your wrist comfortably in
inches. When measurement is inch size, order the next 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.

U
Featuring:

All prices are subject to


change without notice.
Persona Inspiring Style is a trademark of Personal Limited
ROOTS is a registered trade-mark of Roots Canada Ltd.

Wrist
size

Standard
bracelets

5
5
6
6
7
7
8
8
9

5
5
6
6
7
7
8
8
9

Beaded
bracelets

Bicycle
chains

Expansion
bands

M
L

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 watch

save

CHOOSE YOUR STYLE:

Dont face an em
Emergency Hotli
alert your loved
with you.

notifi

When your life is


our 24/7 Emerge
in 5 seconds, sp
provide your full

24/7 p

When youre ove


MedicAlert ID an
paramedics the i
save your life.

speaK

Your members
Heres how:

mem
bene

Personal Information
Are you, or have you ever been a MedicAlert member? No Yes MedicAlert ID#
First Name

Last Name

Communications English French

Mr. Mrs. Ms. Dr.

Date of Birth (m/d/y)

Gender M F

Mailing Address

Apt.

City

Province/Territory

Best # to contact (

Alternate Tel. (

Best time to call:

Postal Code

ext.

Email

Not available

Required

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

Phone (

Prov.

Alternate Tel. (

Postal Code

E-Mail

Emergency Medical Contacts


Physician 1
Tel. (

Specialty
)

ext.

Physician 2
Tel. (

Is this the Referring Physician?


Specialty

ext.

Personal Emergency Contacts (family/friends)


1. Name

Home Tel. (

Relationship
)

Alternate Tel. (

Alternate Tel. (

2. Name

Home Tel. (

Relationship

I give permission to the emergency contacts above to access my medical information.

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
NMA13N

Choose a style from this brochure or visit medicalert.ca/save to see more


Measure your wrist size if ordering a bracelet or watch
Place the product code, product name, preferred size (sizing information on product page) and price in the appropriate columns
Fill out the order form as directed (combined provincial tax, membership, payment option)
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

shaded areas must be filled in


Product Size

Price

Product Name

A
B

AB, YT, NT, NU


5.00%

ON, NB, NF
13.00%

Monthly = $5*;

NS
15.00%

BC, MB
12.00%

15 months = $75;

SK
10.00%

QC
14.975%

Shipping & Handling

Taxable Amount
(add lines A, B & C)
PEI
Sales Tax
14.00%
(Line D x prov. tax from chart on left)
Subtotal
(add lines D & E)
Registration Fee
(One time fee for initial medical record set up)

24 months = $110;

36 months = $150

Membership Fee

$8.99

E
F
G

$24.00

Total
(add lines F, G & H)
*I give permission to charge my credit card or debit my bank account monthly to keep me protected.
*Available with credit card and debit payment only.
Prices are subject to change without notice.
GST/HST Registration # 10686 3293
QST Reg. #1022707074
National Registered Charity # 10686 3293 RR0001

METHOD OF PAYMENT

Cheque

Please make cheque payable to Canadian MedicAlert Foundation

VISA
MasterCard
American Express

Credit Card #

Bank Account Debit

I authorize Canadian MedicAlert Foundation to debit my bank account for membership payments and fees (void cheque enclosed).

Name as it appears on card

Expiry Date (m /y)


Signature

Ensure you read and sign the member statement below


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 file 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 file 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 file 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 file online or by calling us. You are responsible for making sure that
the information in your file is correct. MedicAlert will not be responsible for any harm
caused because the information in your file 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.

You will receive special promotions and info on third party programs that may be of
interest to you, unless you decline below.
Communication
Email (E); Mail (M); Mobile/Text (T); Do Not Send (D)
All
Newsletters & member stories
MedicAlert product news
MedicAlert offers & promotions
3rd party partner offers
Information about charitable work
MedicAlert
Alzheimer Society

Method
E
M

You ACKNOWLEDGE and agree that you have read and understood the MedicAlert
Member Statement available online at www.medicalert.ca or by calling 1.855.724.2499.
If you are not the applicant, you have the permission of the applicant or a legal right to
complete this form on behalf of the applicant.
Signature

Date

Name (print)

Phone number

Relationship to member

COMPLIMENTARY RULER. Measure your wrist size and refer to complete sizing information on opposite page.

Order Form Product Code #

TYLE:

nity Links Sterling


ver Bracelet
87 / $249
garo Sterling Silver Bracelet
09 / $99
ano Sterling
ver Bracelet
11 / $199
signer Silver
pansion Bracelet
06 / $119
cycle Chain Bracelet
h Steel Links
69 / $80
ack Sport Band with
ainless Steel emblem
09 / $40
ots Mens Watch with
ainless Steel emblem
50 / $99
erling Silver Bracelet
00 / $99
ecial Gold Bracelet ld-filled chain - 10K gold
mblem
00 / $449
signer Stainless
eel Bracelet
03 / $39
erling Silver
iversal Charm
38 / $80

TION

e your wrist comfortably in


r the next inch size up.

racelets are one size fits all,

Expansion
bands

ge of 10 and beaded
of 3.

Bicycle
chains

1.
2.
3.
4.
5.