Icemedalert members - Registration

Basic data

Username

Password

Confirm password

Organization

Surname

First name

First Line of Address

Enter first line of address including name and or number as appropriate

Street

City

Country

Birthday

Please enter date of birth in format dd.mm.yyyy

Gender

E-mail

GP Surgery Details

NHS Number

In Case Of Emergency Contact Information

Contact Name in case of emergency (ICE)

Relationship of ICE to member

ICE contact telephone number

Allergies and medical conditions

Allergies

(still 255 characters)

Medical aids fitted (e.g Pacemaker)

Do you use an inhaler?

Do you use an Epinephrine Autoinjector (EpiPen)?

Medications

Please enter any regular medication and dosage/frequency e.g aspirin - 2mg 2/day : Candesartan 4mg 1/day

PLEASE SEPARATE EACH ITEM WITH SPACE AND : as above

Medical Conditions - Have you been treated for any of the following conditions

Asthma

Diabetes

Congenital Heart Disease

Chronic Obstructive Pulmonary Disease (COPD)

Hypertension

Any lung/respiratory disease

Ear/eyes/nose/sinus problems

Muscular or skeletal condition

Head injury/Concussion

Altitude or Travel sickness

Kidney Disease

Blood disorder/sickle cell disease

Fainting spells/dizziness

Psychological or emotional difficulties or behavioural/neurological disorders

Seizures

Abdominal or Stomach or digestive problems

Thyroid disease

Excessive fatigue

Obstructive sleep apnea/sleep disorder

Dementia/Alzheimer

Immunizations

(still 255 characters)

Additional information

I consent to the processing of the data.

I understand and agree, that any information I provide to IceMedalert (the trading name of Landseer Trading Ltd) on this form will be accessible to any authorised person(s) who have access to the QR code generated by IceMedalert and entered on this website. However, IceMedalert commit to keeping all information private to the individual member and any authorised official of IceMedalert (or Landseer trading ltd), and not to share the information with any organisation without the written consent of the member (notwithstanding the previous reference to access via QR code). The information contained in this form will be stored on a secure server at all times. As a member you understand that the information contained in this form and database is the sole resposibility of the member to ensure its accuracy, and any errors and consequential actions as a result of the data are the eplicit responsibility of the member. Only the member canupdat the information contained in the datase. IceMedalert will process the data supplied and produce a QR code for the member, and any authorised person (e.g first responder, medical staff etcc), to access. IceMedalert may, from time to time, send standard (free) members relevent marketing material and members agree to recieve same. Paid members may opt out of marketing material at any time. I fully understand that I accept all responsibility for the information contained within this form and database and will not hold any employee of IceMedalert, or Landsee trading Ltd., nor any officer or director of the companies, responsible for any liability for its use or misuse. Checking the box confirms my agreement..For full privacypolicy please open Privacy Policy (icemedalert.com)

Confirm value

Authentication code