ICE MEDALERT MEDICAL FORM
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Do you have an illness, or taking medication that results in you being Immunosurpressed?
Yes (I am immunosurpressed)
Name
John Doe
Date of Birth
February 19, 1967
Email
john.doe@medmail.com
Address
Apartment 7, 12 Frith Street
London, London, SE1 7PB
Mobile
(44) 012-34567890
Home
(44) 012-34567890
Date
Friday, September 3, 2021
Contact In case of Emergency
Name
Jane Doe
Relationship
Wife
Mobile
(44) 078-9123456
Phone Number
(44) 012-346123654
Allergies
With Allergies
Details
Medicine / Antibiotics
penecillin
Food
crab
Insects
wasps
Animals
dogs
Plants
deadly nightshade
Medical aids fitted (e.g. Pacemaker)
Medical Aid Desc.
pacemaker
Do you use an Inhaler (Asthma Rescue)
No
Do You Use an Epinephrine Autoinjector
No
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ICE MEDALERT MEDICAL FORM
Medical Information
Do you have or have had or been treated for any of the following:
Yes/No
Details
Asthma
No
Diabetes No
Congenital Heart Disease
No
Chronic obstructive pulmonary disease (COPD) Yes
Hypertension
Yes
Any lung/respiratory disease No
Ear/eyes/nose/sinus problems
No
Muscular or skeletal condition Yes RA
Had history of a head injury/concussion
No
Altitude or Travel sickness No
Kidney disease
No
Blood disorders/sickle cell disease No
Fainting spells and dizziness
Yes
Psychological or emotional difficulties or
Behavioral/neurological disorders
No
Seizures (please indicate last occurrence):
No
Abdominal, stomach, digestive problems No
Thyroid disease
No
Excessive fatigue Yes
Obstructive sleep apnea/sleep disorders
No
Immunization
Immunized
Contracted
Disease
Details (Including date)
Covid 19 Double Jab
Yes
No
aug 2021 2 jab
Tetanus Yes No 2020
Other (i.e. HIB)
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Terms of Use:
I understand, and agree, that any information I provide to Ice Medalert (Trading name of Landseer
Trading Ltd) on this form will be accessible to any person or persons who have access to the QR
code generated by Ice Medalert and provided to me. The information contained in thsi form will
be stored on a secure server and will be accessible only to authorised ICE Medalert employees and
anyone whom I provide the acces information to via QR code (or individual Webpage address). I
also understand and agree that this information can only be updated by me (the subscriber) using
the ICE Medalert Update form. Ice Medalert will then transcribe this information to a dedicated
(to subscriber) web address which can be accessed for download by anyone who has the, unique
to subscriber, QR code or web address. I further understand that I accept all responsibility for the
information contained in this form and will not hold any employee of ICE Medalert, or Landseer
trading Ltd, nor any director or ocer of the companies, responsible for any liability for its use or
misuse.
Date Signed
September 3, 2021
Signature of Participant (agree to terms of use
above) NOTE: this is a 'representative'
signature generated by touchpad/mouse etc. By
submitting this form you are agreeing to the
terms and conditions by the action of pressing
'Submit' at the end
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4
Please upload a photo here (Head and Shoulders). You
will see a preview first and if it is the correct photo then
please click the upload button that will appear. When it
finishes uploading please press the Submit button below
to finish the questionnaire. We will enter the data into
our membership file and send you an email when this is
completed and your Data registered. We will also assign
a QR code for you to access the records. ICEMedalert
will send you a link where you can update the
information at any time and also a link to the
downloadable membership card
Approval Status
Approved
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