MEDminder™ Card Request Form

Asterisk (*) indicates a required field.

Contact Information

First Name*

Last Name*

Email Address*

Phone Number*

Patient Information

First Name*

Last Name*

Date of Birth*

Allergies*(Please list all allergies, including food, environment, and any medicines)

Emergency Contact*

Emergency Contact Phone Number*

Medicines

Please specify the generic/common name and the trade name, if known.

Medicine #1*

Amount of medicine per dose #1*

Time medicine is taken each day #1*

Any special instructions #1(Please include any special instructions for healthcare professionals in case of an emergency)

Add Medicine Remove Medicine

Design Your MEDminder™ Card

Color*

Do you want your card:*

Unfolded (approximately the size of a dollar bill) Folded in half (fits easily into a wallet)

How do you want to receive your MEDminder™ card?*

Regular mail Email (MEDminder™ card will not be laminated) Both regular mail and email

How did you hear about the MEDminder card™?*

Acknowledgement

MEDminder™ is an optional service offered to St. Jude patients. Since the St. Jude Pharmacy is not directly providing the service, St. Jude cannot promise, represent, or warrant that the information provided is accurate or complete. For questions about the accuracy of the medicine list, please talk with your personal doctor. By providing information and education, our aim is to encourage you to take an active part in your care and treatment Questions about individual health concerns or specific treatment options should be discussed with your doctor. In no event will St. Jude be liable to you or to any third party for inaccurate or incomplete data, lost data or other damages of any kind arising out of the use or inability to use this service.

I have carefully checked for spelling and content and I understand that this information will print exactly as it was entered into the request form. Updates or changes to the MEDminder™ card will require a new form to be submitted.

Initials*

I certify that I am a St. Jude patient or I am completing this form for a St. Jude patient. I understand that individuals who are not St. Jude patients cannot receive a MEDminder card.*

I agree to share this information with St. Jude*
This Service is governed by and operated in accordance with US law. If you are located outside of the US, you use this Service voluntarily and at your own risk. If you choose to submit personal data like your name and email address, please note that your Information will be transferred to and processed in the United States. By checking this box while using this Service, you acknowledge that the data protection and other laws of other countries, such as the United States, may provide a less comprehensive or protective standard of protection than those in your country, and consent to your Information being collected, processed and transferred as set forth in the Privacy Policy and US law.

MEDminder™ Card Request Form

Address to mail card: