Medical Alert NFC Card Questionnaire & Order Form

IF YOU HAVE A "PREPAID" CODE NUMBER, ENTER IT IN THE BOX BELOW:

I AM ENTERING MY MEDICAL ALERT PROFILE FOR THE FIRST TIME*

YESNO

I AM "UPDATING" MY CURRENT MEDICAL ALERT PROFILE*

YESNO

I AM APPLYING AS A SPOUSE WHO ALREADY HAS AN ACTIVE ACCOUNT*

YESNO

I AM APPLYING AS A SPOUSE AND MY SPOUSE'S NAME IS

FIRST NAME: *

LAST NAME: *

STREET ADDRESS: *

CITY: *

STATE: *

ZIP:*

DATE OF BIRTH: *

PRIMARY LANGUAGE SPOKEN: *

I CONSIDER MY PRIMARY ETHNICITY TO BE:

PHONE NUMBER: *

Area CodePhone Number

EMAIL ADDRESS: *

example@example.com

I HAVE AN ACTIVE AND SIGNED DNR ORDER:*

YESNO

MY DNR FORM(S) ARE LOCATED:

PLEASE PROVIDE ALL OF THE LOCATIONS WHERE EMS CAN FIND YOUR SIGNED DNR ORDER

I HAVE AN ACTIVE POLST ORDER:*

YESNOUNSURE

I HAVE AN ACTIVE ADVANCED DIRECTIVE:*

YESNOUNSURE

MY BLOOD TYPE:

Please Select One From The Drop-Down List

I AM A DESIGNATED ORGAN DONOR:

YESNO

MEDICATIONS & DOSAGES: *

If none type "None" (Separate each Medication with a comma)

ALLERGIES: *

If none type "None" (Separate each Allergy with a comma)

DISABILITIES & SPECIAL NEEDS:

If none type "None"

ADDITIONAL MEDICAL INFO:

Please include any significant past medical history including any surgeries and dates when possible

RECENT IMMUNIZATION AND DATES:

RELIGION/BELIEFS/FAITH:

PLEASE INCLUDE ANY SPECIAL CARE OR TREATMENT THAT IS RELATED TO YOUR FAITH

SOCIAL SECURITY/MEDICARE #:

HEALTH INSURANCE CARRIER NAME & POLICY #:

INDIVIDUAL #:

GROUP #:

HEALTH INSURANCE CARRIER NAME & POLICY #: *

If none type "None"

PRIMARY CARE PHONE NUMBER: *

Area CodePhone Number

EMERGENCY CONTACT NAME: *

If none type "None"

EMERGENCY CONTACT PHONE:

Area CodePhone Number

Medical Alert QR Code Card, [BASIC PLAN]$22.99

(Basic Plan) Any medical profile updates are charged on a per change basis. This plan is best suited for anyone whose medical profile changes infrequently. Any profile changes shall require the purchase of a replacement vinyl QR code adhesive sticker which will be mailed to you.

Quantity

Medical Alert QR Code Card, [STERLING PLAN]$34.99

(Sterling Plan) You may update your medical profile once in (365 days) at no additional cost.

Quantity

Medical Alert QR Code Card, [GOLD PLAN]$59.99

(Gold Plan) You may update your medical profile twice in (365 days) at no additional cost.

Quantity

Medical Alert QR Code Card, [PLATINUM PLAN]$99.99

(Platinum Plan) You may update your medical profile up to six (6) timese in (365 days) at no additional cost.

Quantity

Replacement/Duplicate PVC Medical Alert Card with QR Code$24.99

Quantity

Replacement/Modified QR Code Vinyl Adhesive Sticker (By USPS Mail Delivery)$19.99

Quantity

Total $0.00

This HOLD HARMLESS AGREEMENT (this “Agreement”) is made effective on the initial purchase date by and between MedicalAlertCard.org,and/or SOL Specialties of The Villages, Florida, and purchaser. Both are sometimes individually referred to as “Party” and collectively referred to as the “Parties.”‘WHEREAS, as the purchaser I desire to hold harmless MedicalAlertCard.org, and/or SOL Specialties and its employees/agents from any claims and/or litigation arising out of actions in connection with the purchase and use of the Medical Alert Card. NOW, THEREFORE, in consideration of the mutual covenants and conditions contained herein, both hereby agree as follows: TERMS 1. Hold Harmless. As the purchaser, I shall fully defend, indemnify, and hold harmless MedicalAlertCard.org, and/or SOL Specialties and its employees/agents from any and all claims, lawsuits, demands, causes of action, liability, loss, damage and/or injury, of any kind whatsoever (including without limitation all claims for monetary loss, property damage, equitable relief, personal injury and/or wrongful death), whether brought by an individual or other entity, or imposed by a court of law or by administrative action of any federal, state, or local governmental body or agency, arising out of, in any way whatsoever, any acts,omissions, negligence, or willful misconduct on the part of its officers, owners, personnel, employees, agents, contractors,invitees, or volunteers. This indemnification applies to and includes, without limitation, the payment of all penalties, fines, judgments, awards, decrees,attorneys’ fees, and related costs or expenses, and any reimbursements to MedicalAlertCard.org by the buyer, for all legal fees, expenses, and costs incurred by it. 2. Authority to Enter Agreement. Each Party warrants that the individuals who have signed this Agreement have the actual legal power, right, and authority to make this Agreement and bind each respective Party. 3. Amendment; Modification. No supplement, modification, or amendment of this Agreement shall be binding unless executed in writing and signed by both Parties. 4. Waiver. No waiver of any default shall constitute a waiver of any other default or breach, whether of the same or other covenant or condition. No waiver, benefit, privilege, or service is voluntarily given or performed by a Party shall give the other Party any contractual right by custom, estoppel, or otherwise. 5. Attorneys’ Fees and Costs. If any legal action or other proceeding is brought in connection with this Agreement, the successful or prevailing Party, if any, shall be entitled to recover reasonable attorneys’ fees and other related costs, in addition to any other relief to which that Party is entitled. In the event that it is the subject of dispute, the court or trier of fact who presides over such legal action or proceeding is empowered to determine which Party, if any, is the prevailing party in accordance with this provision. 6. Entire Agreement. This Agreement contains the entire agreement between the Parties related to the matters specified herein and supersedes any prior oral or written statements or agreements between the Parties related to such matters. 7. Enforceability, Severability, and Reformation. If any provision of this Agreement shall be held to be invalid or unenforceable for any reason, the remaining provisions shall continue to be valid and enforceable. If a court finds that any provision of this Agreement is invalid or unenforceable, but that by limiting such provision it would become valid and enforceable, then such provision shall be deemed to be written, construed, and enforced as so limited. The intent of the Parties is to provide as broad an indemnification as possible under Florida law. In the event that any aspect of this Agreement is deemed unenforceable, the court is empowered to modify this Agreement to give the broadest possible interpretation permitted under Florida law. 8. Applicable Law. This Agreement shall be governed exclusively by the laws of Florida, without regard to conflict of law provisions. 9. Exclusive Venue and Jurisdiction. Any lawsuit or legal proceeding arising out of or relating to this Agreement in any way whatsoever shall be exclusively brought and litigated in the federal and state courts of Florida. Each Party expressly consents and submits to this exclusive jurisdiction and exclusive venue. Each Party expressly waives the right to challenge this jurisdiction and/or venue as improper or inconvenient. Each Party consents to the dismissal of any lawsuit that they bring in any other jurisdiction or venue. 10. Signatures. This Agreement shall be presumed to be pre-signed by Seller and effective as of the initial purchase date/buyer’s signature. I knowingly release from all liabilities and voluntarily provide MedicalAlertCard.org and its employees/agents with my personal medical information for the sole purpose of encoding it into a Medical Alert Card which shall be delivered to me for my personal use. I acknowledge that I can withhold any information that I do not wish to share. I authorized EMS Personnel to utilize my information to assist them in providing me with any emergency medical services. I understand that MedicalAlertCard.org pledges to never use, sell, trade or provide my personal information to anyone. PLEASE SIGN IN THE BOX BELOW*

PLEASE WRITE YOUR SIGNATURE USING YOUR MOUSE OR YOUR FINGER WITHIN THE BOX

PLEASE REVIEW YOUR ENTRIES AND PRESS THE BLUE SUBMIT BUTTON WHEN FINISHED

NOTICE

FOR YOUR SAFETY AND SECURITY THIS FORM WILL BE WIPED FROM THE SERVER WITHIN 24 HOURS AFTER COMPLETION

THE VILLAGES STRAIGHT SHOOTERS MEDICAL ALERT CARD QUESTIONNAIRE ORDER FORM

PLEASE SELECT THE MEDICAL ALERT PRODUCT(S) YOU WISH TO PURCHASE:

YOUR SIGNATURE IS REQUIRED IN THE BOX BELOW