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Electronic Medical Records (EMR)
The Most Advanced and Cost Effective Unit Available!
Your Own Personal, Private, Safe and Secure EMR
and for all healthcare providers!

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US 		EMRpetStick DATA INPUT FORM



The EMRStick® Data Input Form


Go here for other forms

DATA INPUT FORM
(Copyright 2007 Medstick Corporation, Patent & Trademark Pending)
Use the following form to input your personal data and data from each of your providers and Emergency contacts. A sequence is followed which enables all your data to be loaded onto your own EMRStick®.

You will receive your own personal EMRStick® to carry in your wallet, purse, vehicle, around your neck or on your keychain which will have vital data that those treating you can use should a medical emergency, medical challenge or regular care arise. Other family members are also urged to carry their own EMRStick®. Please complete a separate form for each member of your family who is to have their own EMRStick®.

To enter data to your own personal EMRStick®, you will need to create a unique User Name and Password for yourself and for each member of your family. Enter each family member on a separate form. With this login  you can add, view and change your data after your account is setup as well as make any necessary updates.

If you cannot remember the data needed, we suggest you request a copy of your health records from all your healthcare providers, including your general practitioner, plus your eye doctor, dentist, and any other specialist you have seen. This data will give you what you need to set up your own personal EMRStick® and one for each of your family members and relatives.

A number of SECURITY MEASURES are used to safeguard and protect the database. Only the EMRStick® holder or others specifically authorized by the holder, can access the database. This ensures personal information remains personal, especially if your EMRStick® has been lost or stolen.

If you are requesting data from your physician ask for an "Authorization for the Release of Information" form from your physician. Or - you may requesst a form from Medstick Corp. simply by sending us an email (larry@emrstick.com) with the subject Input Data Forms Adult or Child or a letter. Complete the form and return it to us or your physician/provider as directed. Most facilities do charge for copies. The fee can only include the cost of copying (including supplies and labor), as well as postage if you request the copy to be mailed. It can take up to 60 days to receive your medical records (in the US), so ask when you can expect to receive the information you requested.

If you prefer to complete a paper form on-line - complete and print the form below and mail it to us or just click on the button at the end of the form and it will come to us automatically. For the Child Form click here or for the EMRpetStick input data form (for printing or on-line completion) - Thank you!


Please complete the following form (Adult):


Personal Information


 *Required

 *Establish your own ID and Password (Maximum 12 characters): ID 
 Password (Maximum 12 characters): 
 (Make sure you make a note of these for reference)
 *Enter your EMRStick Representatives code number (Maximum 8 characters): ID 




 Today's Date:  

    *Name:          
    *Address1:       
     Address2:      
    *Town/City/Village: 
 
           *State - USA:  
              Zip Code:        
              Province:  
              *Country:   	
    *Home Phone Number:  
    *Cell Phone Number:   (If available)
    *Email Address:       (If you have one)
    *User Name:    (Create your own - (keep a copy of it)
    *User ID:      (Create your own - (keep a copy of it)
  *Gender:  Male  or Female       
  *Your native language: 
             *Birth Date: Month  Day:  Year:  *Age:  
  *Weight: Kilos   Lbs 

  *Blood Type: Type 
 
  *Organ Donor: (Checkmark) No Yes  

  *Insurance Coverage: (Optional)
	(Name of Company and Plan only) 
	(Name of Company and plan only) 
	(Name of Company and plan only) 
	(Name of Company and Plan only) 

    *Your Internet Address:   (Optional)

   Current Health Concerns:
	Date:  Concern: 
	Date:  Concern: 
	Date:  Concern: 
	Date:  Concern: 
	Date:  Concern: 

	
   Current Medications: (List)
	   Medication 1: 
        Dose and Frequency: 
	   Medication 2: 
       Dose and Frequency: 
	   Medication 3: 
       Dose and Frequency:   
	   Medication 4: 
       Dose and Frequency: 
	   Medication 5: 
       Dose and Frequency: 
	   Medication 6: 
       Dose and Frequency: 
	   Medication 7: 
       Dose and Frequency:   
	   Medication 8: 
       Dose and Frequency: 


   Allergies to Medicine: (list) 
	 
	  
	 
	 


   Past Medical History: (Date and brief description)
	 
	 
	 
	 

   Past Surgical History:  (Date and brief description)
	 
	 
	 
	 

   Personal Physicians/Care Providers
 
        (Name - Type/Speciality - Office Phone/Other contact numbers)
	   
	   
	   
	   

   Emergency Contacts: (Name/Relation Phone-contact)
	 
	 
	 
	 
	 


      (Name and Number of Medstick Representative)
	 



   
IMPORTANT: A PASSPORT SIZE PHOTO IS REQUIRED!!
	Take or have a photo taken and then store it on your computer.
 The photo should be 1.25" x 1.75". Later you will download it 
	or send it to us to put on your EMRStick



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MedStick Corporation 3619 E Verdin Rd., Phoenix, Arizona 85044 Tel/Fax: (480) 899-4463
For questions please contact us via email: elainemurrary@live.com