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Over 75 pertinent medical items listedYour persona^ identification \Quick reference chart lists blood type, allergiesmedicine currently being takenPersonal physician^sname & numberFill out school, camp, service or job applications and insurance forms quickly and accuratelyI t I m e meTHODiST* HOSPITALi gtrAm erican AMBULANCE & OXYGEN SERVICEWarning stickers for special medical problemsEntire medical history on microfilm sealed into cardMethodist Hospital phone number for quick referenceIssue date shows how current information isminutes and we%u2019llsend you the card that may save your life.FREE, The Care Card from Methodist Hospitaland American Ambulance Co.This card contains all of your vital medical information on a tiny microfilm that can be read in any Emergency Room or doctor%u2019s office.The Care Card supplies information Emergency Room personnel may need in an emergency. Important information about allergies, blood type, or medical problems that could save your life when you may be confused or unable to give that information.The Care Card Does MoreThe Care Card is just as valuable in everyday situations. It %u201c remembers%u201d information you may forget to give a doctor.It reduces time spent filling out forms in hospitals and doctors%u2019 offices. And the card is a ready reference when filling out forms and applications.Fill out the form below and send it to us today. We recommend that you consult with your doctor to make sure the information is accurate and up-to-date. Within four weeks, you%u2019ll receive your Care Card in the mail. We%u2019ll also include two florescent red stickers - one for the back of your driver%u2019s license, the other for the back of your car%u2019s rear view mirrow - which will alert rescue personnel that you%u2019re carrying the card.Contact us and we%u2019ll send additional forms for children and other family members.Methodist Hospital and American AmbulanceThe card is absolutely free. We are leaders in providing health care service to the community, and we%u2019re making this contribution to better the welfare of Brooklyn.It takes only five minutes... And that could save your life. Mail to:Daniel G. RowlandDirector of Development and Public Affairs The Methodist Hospital of Brooklyn 506 Sixth Street Brooklyn, N.Y. 11215 718/780 3370American-Methodist Health ServicesINSTRUCTIONS:1. Please type or prin t in black ink for all w ritten sections2. Sign all authorizations an d have them prop erly witnessed. M ino rs must have theirform signed by a paren t or guardian.3. All sections should be com pletely filled out. If you have doubts about any medicalcondition, consult your physician before com pleting the formEMERGENCY MEDICAL INFORMATION______________________________ _Nam* (Last name) firit Mk) Im Oat# ol BirthTat*pt>ona NumberManual Statu* Ra%u00bb*o*on (optional) Employer (Co Nama and Ptvona a)Mad teal Inauranca Co and Pohcy NuntbarHava you avar baan traatad at Tha Mamoditt HoapdalPtiytiCian * Mama and Phona NumbarIf C A R D h o ld e r is a m in o r, pleaae list parents%u2019 em ployersYour E m plo yer _____ ______ __________________ S pouse s E m ployerPtv<9%u00bb N u m b e r . C ity /S ta te _____ptione Number . . C lty /S ie te ---------PCRtOMS/NCXT OF K IN TO K NOTIFIED M C A N O f CMKROEMCYJ ..J ..._ L _ J _U S T ALL O eW A T fO N A fM C LU O C Y IA ft)MEDICALINFORMATION(Black in boxes complataly d applicable to you)%u25a1 Anemia%u25a1 Arthritis%u25a1 Asthma%u25a1 Blind%u25a1 Cancer%u25a1 Cataracts%u25a1 Cerebral Palsy%u25a1 Cirrhosis%u25a1 Contact Lenses%u25a1 Cystic Fibrosis%u25a1 Deat%u25a1 Diabetes%u25a1 Dentures%u25a1 Emotional Problems%u25a1 Emphysema%u25a1 Epilepsy%u25a1 Glaucoma%u25a1 Heart Condition%u25a1 Hemophilia%u25a1 Hepatitis%u25a1 Hodgkins Dis ase%u25a1 Hypertension%u25a1 Hypoglycemia%u25a1 Implanted Pacemaker%u25a1 Kidney Disorder%u25a1 Mental Illness%u25a1 Mental Retardation%u25a1 Missing Paired Organ%u25a1 Muscular Dystrophy%u25a1 Multiple Sclerosis%u25a1 Mute%u25a1 Myasthenia Gravis%u25a1 On Chomotherepy%u25a1 Paralysis%u25a1 Psychiatric Treatment%u25a1 Rheumatic Fever%u25a1 Rheumatoid Arthritis%u25a1 Sickle Cell Anemia%u25a1 Stroke%u25a1 Tuberculosis%u25a1 Ulcer%u25a1 Taking Anticoagulant%u25a1 Taking Cortisone%u25a1 Taking Methadone%u25a1 Taking Steroids%u25a1 Other Medical Problems%u25a1 OtherAUJEUOIC TO:%u25a1n%u25a1 Aspirin%u25a1 Codeine%u25a1 C %u25a1 0%u25a1 tnaoci Sungs%u25a1 I V P Dyee%u25a1 If%u25a1 Tetanus Totoxf%u25a1 OtherLIST ALL CU RREN T MEDICATIONSLIST CHRONIC ILLN ESSESDATE OF LAST IMMUNIZATIOND R T . ___________________________Tetanus T oxo id -BLOOD TYPE(Check H known)%u25a1 Positive %u25a1 Negative%u25a1 0 O BD A D A BW ould you b%u00ab interested in b ecom ing eM ethodist H ospitel B lood Donor?%u25a1 Yes %u25a1 NoH s v t you d o n eted blood w ithin th e pastyear?D Yes %u25a1 N oASSUMPTION OF RESPONSIBIUTY FOR CORRECTNESS(You must sign to va M rte)i HEREBY CERTIFY that i nave read this completed form and the! alt informationrecorded on thie form is true, correct end accurate to the beet of my knowledge endbelief I agree to aaaume complete reeponeibility tor the truth, correctness endaccuracy ol that information. Further. I hereby agree, individually, end on behalf ofmy egante. halre. successors, or assigns, not to assart any claims against Mad-CardSystams. The Methodist Hospital and American Ambulanca and its employees,agents, subcontractors, suppliers, and/or emergency personnel, or any otherendorsing company or group (end their respective officers, directors, employees,successors, end affiliates) in tew or equity tor liability arising from or in connectionwitha) any inaccuracy or omission of information provided on this form.b) the performance or lack of performance of any service relating to the form ofmy Methodist Hospital and American Ambulance Cara Card orc) any damage to my Methodist Hospital and American Ambulance Cara Card (orits components)Date signed SignatureWitnessOctober %u00bb, 1M L THI PHOOttt, N g%u00bb 7