Patient Partner Information Form

Your Name or Organizations Name as you want it listed on the My Rare ID website

Your Personal Logo to use on the My Rare ID Website (300x300)

Click or drag a file to this area to upload.

Primary Contact Name (My Rare ID Use Only) *

First

Last

Primary Contact Email (My Rare ID Use Only) *

Your Website URL

Affiliate Email for Your Login to your My Rare ID Profile *

Preferred Affiliate Code

This will be the code used by your community members during the checkout process. The code should be at least 4 characters and be recognizable by your organizations members.

Awareness Day Name

If your organization has an awareness day or month you can list what the name of the day is here.

Awareness Day Date

You can list the dates and times here for your awareness day(s).

Resource Links Section

In this section you can list up to 6 resources for community members to have listed on their profile. These resources should be educational for Emergency Medical Staff. If you have more than 6 resources please contact us by email at hello@myrareid.co.

Resource 1 Name

Resource 1 Website / URL

Resource 2 Name

Resource 2 Website / URL

Resource 3 Name

Resource 3 Website / URL

Resource 4 Name

Resource 4 Website / URL

Resource 5 Name

Resource 5 Website / URL

Resource 6 Name

Resource 6 Website / URL

Social Media Channels

FaceBook

Twitter

Instagram

YouTube

Other Channel

When and how you would like to cross promote

Patient Partner Information Form

Resource Links Section

Social Media Channels

Contact us

Recent Posts

Shop Our Store

Useful Links

Your Shopping cart