ICE Card Form – Stainless Charm (Pty) Ltd. T/A MedAlertSA, LIFEfolio

Form: ICE-PMCARD

ICE Medi-Card™ (Plain) Application Form

Personal Information of Applicant:

First

Last

Delivery Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Delivery / Courier Options

Please choose the appropriate option.

WhatsApp Contact Number:

Email Address:

National ID Number

Please provide your South African ID number.

Date of Birth (DD/MM/YYYY):

Please provide your date of birth.

Medical Birth –

File Upload – Copy / Photo of National ID Card

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Please upload clear images of both the front and back of your national ID card. This will assist emergency personnel in verifying your information.

Medical Aid Name & Number

Please provide the name and number of your medical aid. (E.g. Polmed – 123456)

File Upload – Copy / Photo of Medical Aid Card (If Needed)

Drag & Drop Files, Choose Files to Upload You can upload up to 2 files.

Please upload clear images of both the front and back of your medical aid card. This will assist emergency personnel in verifying your coverage and accessing critical medical information.

Medical Conditions

Kindly provide the most critical medical conditions. (E.g. Diabetes, Severe Allergies (Bee Sting), Epilepsy)

Medication

Kindly provide the most critical medications. (E.g. Insulin, EpiPen, Blood Thinners, Nitroglycerin, Valproate)

Blood Group

Emergency Contact Name & Number (ICE) #1:

Please provide the name and number of the primary emergency contact.

Emergency Contact Name & Number (ICE) #2:

Please provide the name and number of the secondary emergency contact.

Feel free to add any additional information or ask for more details if needed.

This is an extra field for your convenience.

Review Submitted Information (Confirmation step before submission):

Yes, I confirm that all data is accurate.

**Declaration of Accuracy** By confirming, you acknowledge that the information provided is accurate and up-to-date to the best of your knowledge. This ensures that the details linked to your Medi-Card are reliable and can assist first responders in providing appropriate care during emergencies. **Why are we asking this?** This step gives you an opportunity to double-check all the details you’ve entered before finalizing your submission. Ensuring accuracy is vital, as this information will be used in emergencies and linked to your Medi-Card. Taking a moment to review helps avoid errors and ensures responders have the correct and complete details when they need it most.