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Sample Profile – John Palmer
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Subscriber Details
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Subscriber Details
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Patient Info
Name
*
First
Last
Upload Your Picture (200w x 100h)
*
Click or drag a file to this area to upload.
Brief description of yourself and your condition
Birth Date
*
Gender
*
Male
Female
Ethnicity
*
Blood Type
*
A+
B+
A-
B-
AB+
AB-
O+
O-
Height (Feet & Inches)
*
Weight (lbs)
*
Hair Color
*
Eye Color
*
Religion
Allergies
Example: Strawberries, Penicillin
Are You An Organ Donor
*
Yes
No
Do you wish to be an organ donor?
Dietary Description
Are you on special diet? Keto? Mediterranean? Gluten Free? Or another diet.
Emergency Info
Urgent Condition
Emergency Treatment
Allergic To:
Example: Strawberries, Penicillin
Supporting Website / URL
Supporting Website / URL
Supporting Website / URL
Current Diagnoses
Diagnosis Description
Diagnosis Link
Diagnosis Description
Diagnosis Link
Additional Diagnosis
Treatment Protocols
Treatment Document
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Treatment Document
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Treatment Document
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Treatment Document
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Treatment Document
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Insurance Information
Insurance Company Name
Member ID
Group ID
RXBIN
RXPCN
RX Group
Front of Insurance Card
Click or drag a file to this area to upload.
Back of Insurance Card
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Known Medical Conditions
Medical Condition
Medical Condition Website Link
Medical Condition
Medical Condition Website Link
Additional Medical Conditions
Allergies
Example: Stawberries, Penicillin
Birthmarks
Symptoms to Watch For
Lists of Symptoms
Symptom Description Link
Symptom Description Link
Current Medications
List of Medications / Dosage / When Taken
List your medications, your dosage, how often and time of day the medication(s) are taken
Medication Link
Medication Link
Medication Link
Medication Link
Vaccinations
Vaccination
Vaccination Date
Vaccination
Vaccination Date
Vaccination
Vaccination Date
Additional Vaccinations & Dates
Emergency Contact Info
Emergency Contact 1
Emergency Contact 1 Phone
Emergency Contact 1 Relationship
Emergency Contact 1 Notes
Emergency Contact 2
Emergency Cotnact 2 Phone
Emergency Contact 2 Relationship
Emergency Contact 2 Notes
Additional Contacts
Treating Physicians
Physician 1 Name
Physician 1 Phone
Physician 1 Specialty
Physician 2 Name
Physician 2 Phone
Physician 2 Specialty
Physician 3 Name
Physician 3 Phone
Physician 3 Specialty
Additional Physicians
Previous Surgeries/Implants/Devices
Surgery 1
Surgery 1 Date
Date
Time
Surgery 1 Notes
Surgery 2
Surgery 2 Date
Surgery 2 Notes
Additional Surgeries
Glasses and Contacts
Glasses / Contacts
I wear glasses
I wear contacts
Recent Test Results
Recent Test Results
Family History
Relationship 1
Example: Father / High Blood Pressure
Relationship 1 Notes
Relationship 2
Relationship 2 Notes
Additional Family History
Other Additional Information
Additional Information
Example: • Carries royal blue NorthFace backpack • Avid bike rider • Wears Apple watch • Cellphone is an iPhone 13
Notes
Notes
File Repository
File Upload
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File Upload
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File Upload
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PIN #
*
Password
Confirm Password
Select a 4 digit PIN #
Included on Your Card
*
Birthdate
Gender
Ethnicity
Blood Type
Height
Weight
Hair Color
Eye Color
Allergies
Medical Condition
By Default: Your Name, Picture, Birthdate, My Rare ID, and PIN # will appear. You can include up to 5 additional items from your profile.
Sample Card
John Palmer
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