Quik Script Emergency Medical Card

The QUIK-SCRIPT™ Emergency Medical Card gives you two easy options for ordering your life saving emergency medical card. Downloadable order forms are available to send in your information or order by secure payment online.

Please complete all the information below.

Personal Information for Medical Treatment

Name
Address		Apt.
City, State, ZIP
Telephone	Area Code
	Last 4 Digits of your Social Security Number
Year of Birth		Blood Type
Living Will?
*DNR?

Emergency Contact

Name
Relationship	Telephone

Physician Information

Primary Physician and Telephone
Other Physician and Telephone
Other Physician Type (example cardiologist)
Insurance Provider / HMO:

Medical Information

Allergies
Medical Conditions

Medications

Medication, Dosage, Frequency (example: Aspirin, 80mg, 1 per day)

1.		2
3.		4.
5.		6.
7.		8.
9.		10.
11.		12.
13.		14.
15.

By submitting below, I attest I am solely responsible for the accuracy of the information provided AND I am solely responsible for updating QUIK-SCRIPT with any change of information.

*DNR Means - Do Not Resuscitate

QUIK-SCRIPT TM complies with all HIPPA regulations regarding information privacy and confidentiality.

QUIK-SCRIPT TM will provide an updated replacement card up to two times within the first year of purchase at no charge.

Please Allow 2 to 4 Weeks for Delivery

Downloadable forms can be opened in Word Pad or MS Word. Print in information and send to address stated on the form.

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