iCare ID Card Form for Individuals with Medical Concerns

Diagnosis/Medical Concern *

Enter a title of health concern or diagnosis such as Epilepsy, Heart Condition, Type 2 Diabetes, etc.

First and Last Name *

Date of Birth *

Phone Number *

Enter your phone number

Medical Concerns

Enter a short sentence about medical condition such as, "I have a pace maker" or "I may fall at any given moment" etc.

Special Instructions

Enter your specific needs if contacted by a by standard or medical professionals during a health crisis

Allergies

Enter any life threatening allergies to foods, medications, insects, etc.

Emergency Contacts *

Enter Name and phone number of emergency contacts. Limit to 3 contacts.

Doctor Name

Doctor Phone Number

Medications

List your medications here

Name

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