Miami Valley Dayton OH Chapter  -  Harley Owners Group®
        ... Create Your Own "Emergency Medical Information Card" Online

Follow these simple instructions below:

1. If you wish to print a BLANK form, just leave all answers blank, and click on the "Make me an Emergency Medical Information Card" button, or...
   
   

2. If you wish to fill out the form electronically, fill any of the  information requested on the form below, and press the "Make me an Emergency Medical Information Card" button.
   Note that NO information is stored or collected anywhere on ANY computer.  Also, note that you do NOT have to fill out any information you do not wish to print out on the card.
   
   

3. Be patient; the processing of your data will take a few moments.
   When your Adobe Acrobat Reader shows you the completed form, you have the option to either save it on your local computer or to print it on your very own printer.  You can then bring the form to any Monthly Chapter Meeting and ask to have it laminated.
   
   

4. Carry the laminated card with your driver's license. You can also make a backup card to carry with your motorcycle registration.

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Name:
DOB:
Address:
City:
State:
Zip:
Home Phone:
Emergency Contact:
Address:
City:
State:
Zip:
Primary Emergency Phone:
Alternate Emergency Phone:
Relationship:
Medications taking now:
Allergies to medications:
Medical Conditions (diabetes, epilepsy, heart conditions, etc.):
Medical History (surgeries, traumas, heart attacks, etc. and year):
Physician's Name:
Phone:
Medical Insurance Company:
Policy Number:
Group Number:
Member Number:
Blood Type:	A+ A- B+ B- AB+ AB- O+ O-