Yayasan MedicAlert® Malaysia

® (MedicAlert® Foundation Malaysia)

101 Menara Mutiara Majestic, 15 Jalan Ot hman,
46000 Petaling Jaya, Selangor Darul Ehsan, Malaysia
Tel/ Fax: +603 7782 0515 Hotline: +6012 3411137
www.medicalert.com.my
MEMBERSHIP APPLICATION & REGISTRATION FORM
To be completed by applicant and doctor. Please [√] tick appropriate box.
Please mail to: MedicAlert Foundation Malaysia
®
□ New Membership □ Renewal
Or email to: medicalertmalaysia@gmail.com □ Replacement □ Update Membership Information
MEMBER’S DETA ILS

Full Name: ……………………………………………………………………………….….. I/C No: ……….……………….……………….……………..

Sex: (Male / Female) Ethnic: …………..………….. Nationality: ……….………………...….. Date of Birth: ……..….…..……..........

Mailing Address: …………………………………………………………………………...........................................................................

…………………………………………………………………………………………………........................... Postcode: ................................

Occupation: ……….……………………………………………………………………………….……………………………….................................

Phone (Home): ..................................... (Mobile): ............................................ (Office): ..........................................

(Fax): …………………………………..…..…. Email Address: ……………………..……………………………………………….......................

NEXT OF KIN DETA ILS

Full Name: …………….…………………………………………….………………………. I/C No: ……….……...………………...…..………….…...

Ethnic: ………..………….……….. Relationship: ……………………………………….

Address: …………………………………………………………………………......................................................................................

……………………………………………………………………………..…………………………...….............. Postcode: ...............................

Phone (Home): .................................... (Mobile): ............................................. (Office): ..........................................

DOCTOR’ S DETA ILS

Doctor’s Name: …………………………………..…….…….… Hospital/Clinic Name: ………………………………………….…………..……...

Address: …………………………………………………….…………………………………........................................................................

……………………………………………………………………………………………..……………………...…... Postcode: ...............................

Phone (Office): ….................................. (Mobile): ............................................. (Fax): .............................................

MEDICAL CONDITIONS (PLEASE TICK APPROPRIATELY, WILL BE ENGRAVED)
□ Angina □ Emphysema □ Hypothyroidism
□ Arthritis □ Epilepsy □ Immunosuppressed
□ Asthma □ Glaucoma □ Myocardial Infarction
□ Atrial Fibrillation □ Hearing Impairment □ Nephropathy
□ Chronic Obstructive Pulmonary Disease (COPD) □ Hemodialysis □ Neuropathy
□ Congestive Heart Failure □ Hypercholesterolemia □ Retinopathy
□ Coronary Artery Disease □ Hypertension □ Seizure Disorder
□ Diabetes □ Hypoglycemia □ Stroke
□ Others (please specify)
MedicAlert ® Foundation Malaysia is a nonprofit organization registered with the Registrar of Societies with Registration Number 194 (Selangor) pursuant to the Societies Act 1961.
MedicAlert ® Foundation Malaysia relies on contributions to support our 24/7 emergency centre and our professional education efforts.
MEDICAL DETA ILS (PLEASE TICK APPROPRIATELY, WILL BE ENGRAVED)
ALLERGIES MEDICA TIONS BLOOD GROUP
□ Aspirin □ Amaryl □ Isosorbide Mononitrate □ BLOOD
A GROUP
□ Barbiturates □ Aspirin □ Lisinopril
□B
□ Codeine □ Atenolol □ Metformin
□ Demerol □ Coumadin □ Metoprolol □ AB
□ Iodine □ Digoxin □ Plavex □O
□ Latex □ Enalapril Maleate □ Potassium Chloride
□
□ Lidocaine □ Furosemide □ Ranitidine
□ Morphine □ Gemfibrozil □ Triamterene/HCTZ
□ Novocaine □ Glipizide □ Others (please specify) Rhesus
□ Penicillin □ Glyburide □ □ +ve
□ Sulfa □ Hydrochlorothiazide □
□ -ve
□ Tetracycline □ Insulin (type and dosage) □
□ X-Ray Dyes
□ No known allergies
□ Others (please specify)

Details of Adverse Reactions and Additional Medical Information

………………………………………………………………………………………………………………………………………………..............................
…………………………………………………………………………………………………………………………………………….................................
………………………………………………………………………………………………………………………………………….…................................

By accepting membership in MedicAlert ® Foundation Malaysia, I I agree that the facts as stated are correct to the best of my knowledge.
authorize MedicAlert to release all medical and other confidential (kindly stamp doctor’s chop here)
information about me, in emergencies, to other healthcare personnel.
MedicAlert relies upon the accuracy of the information members supply.
Member therefore agrees to defend, indemnify and hold MedicAlert
(including its employee, officers and agents) harmless from any claim or
lawsuit brought by member or others for injury, death, loss or damages
arising in whole or in part out of member’s provision of incomplete or
inaccurate information to MedicAlert.

Signature: ...................................................................... Signature: ......................................................................

(Applicant) (A parent or guardian signature is required for those under the age of 18). (Doctor)
Guardian Name Guardian I/C No. Guardian Relationship

PAYMENTS / MEMBERSHIP FEES

Please complete one of the following columns below and submit the appropriate amount together with this form.
ORDINARY LIFE RENEWAL RATE REPLACEMENT
Membership Fee RM 100 (for 5 years) RM 500 (one time) RM 100 (for 5 years)
Basic Emblem Cost RM 50 each RM 50 each RM 50 each RM 50 each
Donation RM RM RM RM
Total RM RM RM RM
For non-Malaysian, all the above membership fees and emblem costs are doubled.

Cheques or Postal Orders to be made payable to: “Yayasan MedicAlert Malaysia”

Please tick [√] the choice of emblem required: FOR OFFICE USE ONLY
Registration Date: ………….…….………….……………………
□ Neck Pendant □ Wrist Bracelet Registration No: ……..……..……/…….………/MAL
Basic emblem cost RM 50 each Cash/PO/Cheque Payment Ref#: …...………………….……
Process Date: …………….………………………………………….
Processed By: …………………………….…………………………
Membership Expir y Date: ………………………….……………
Pictures shown above are for illustration purposes only “Protecting and Saving Lives”
MedicAlert Application Form (October 2013)