3 easy ways to enrol this jewelry could save your life

,
s
3 easy
ways
to
enrol
r’s
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.
Don’t 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.
Here’s 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. (
)
/
T
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.
Don’t 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 you’re 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
C
B
A
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
B
Your membership protects you 24/7.
Here’s 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
A
membership
benefits
G
When you’re overwhelmed or hurt, your
MedicAlert ID and membership give
paramedics the information they need to
save your life.
are you
at risK?
C
D
E
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
I
• diabetes
• Alzheimer’s
• asthma
• memory loss
• allergies
• seizures
• heart conditions • pacemaker
J
24/7 protection
K
L
• hypertension
• blood thinners
M
• 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
O
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.
J
2.
Chels
Silver
#423
* With S
SIz
3.
Use a clo
inches. W
P
Q
Use the
Our Roo
and fit w
❏ Mr. ❏ Mrs. ❏ Ms. ❏ Dr.
notifies family
Necklace
products
Wri
siz
R
Don’t face an emergency alone. Our 24/7
Emergency Hotline specialists immediately
alert your loved ones, and
even follow up
S
with you.
T
U
MedicAlert is a registered charity, not a business.
We’re 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
5½
6
6½
7”
Me
7½
A8N
8½
9
A Roots Leather Cuff Slim
Combo - White and Black with
one Stainless Steel emblem
#257 / $75
C
D
H
I
L
M
E
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 Men’s 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 ¼ inch size, order the next ½ inch size up.
Q
P
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.
T
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 ½”
6”
6 ½”
7”
7 ½”
8”
8 ½”
9”
5”
5 ½”
6”
6 ½”
7”
7 ½”
8”
8 ½”
9”
Beaded
bracelets
Bicycle
chains
6
S
7
M
Expansion
bands
S
8
L
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:
Don’t 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 you’re ove
MedicAlert ID an
paramedics the i
save your life.
speaK
Your members
Here’s 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
C
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)
D
24 months = $110;
36 months = $150
Membership Fee
$8.99
E
F
G
$24.00
H
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
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
T
❏
❏
❏
❏
❏
D
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
❏
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 Men’s 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 ½ inch size up.
racelets are one size fits all,
S
M
L
Expansion
bands
ge of 10 and beaded
of 3.
Bicycle
chains
S
M
L
1.
2.
3.
4.
5.