• ICE MEDALERT MEDICAL FORM

    To be completed by member applicant and/or update for member
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  • Contact In case of Emergency:

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  • ALLERGIES

    Please include ALL allergies
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  • Medical Information

  • Further Information

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  • Terms of Use:

    I understand, and agree, that any information I provide to ICE Medalert (Trading name of Landseer Trading Ltd) on this form will be accessible to any person or persons who have access to the QR code generated by Ice Medalert and provided to me.  The information contained in this form will be stored on a secure server and will be accessible only to authorised ICE Medalert employees and anyone whom I provide the acces information to via QR code (or individual Webpage address).    I also understand and agree that this information can only be updated by me (the subscriber) using the ICE Medalert Update form.    ICE Medalert will then transcribe this information to a dedicated (to subscriber) web address which can be accessed for download by anyone who has the, unique to subscriber, QR code or web address.   I further understand that I accept all responsibility for the information contained in this form and will not hold any employee of ICE Medalert, or Landseer trading Ltd, nor any director or officer of the companies, responsible for any liability for its use or misuse by anyone.    I confirm that this information is correct to the best of my knowledge and that there will be no liability arising from the use of said information by authorised medical staff

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  • Thank you for filling the form. Please click the 'Submit' button below and the form will upload and be reviewed. You will receive an e-mail confirming that we have uploaded the information to our database shortly. If you are a new member you will receive an email with a link to where you can access your new membership page and download a membership card with your unique QR code. This QR code is your link to the medical information you have completed above and will be available for First Responders etc that need to access this information by scanning your QR code on mobile phone/tablet etc. If you purchase any of our ICEMedicalert Jewellery this unique QR code will be engraved on the Jewellery (upon request) and regardless of any future updates to the data, the QR code will remain unchanged.

    If you experience any difficulty completing this form please contact us at info@icemedalert.com or call us on 07866435212 (office hours)
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