easy2 — Emergency Medical ID Registration

easy2.co.za

Emergency medical ID registration

Card holder details

First name

Last name

Date of birth

Gender

Blood group

Allergies

Tick all that apply. Use the free text field for anything not listed.

Medication

Penicillin

Amoxicillin

Aspirin

Ibuprofen

Sulfa drugs

Codeine

Morphine

Tetracycline

Contrast dye (X-ray / CT)

Food

Nuts / Peanuts

Shellfish / Seafood

Eggs

Dairy / Lactose

Soy

Wheat / Gluten

Environmental / Other

Latex

Bee / Wasp stings

Insect stings

Plasters / Adhesives

Iodine

Other allergies not listed

Separate multiple entries with a comma

Medical conditions

Tick all that apply. Use the free text field for anything not listed.

Cardiovascular

Hypertension (high blood pressure)

Hypotension (low blood pressure)

Angina

Pacemaker fitted

On blood thinners

Heart failure

Previous heart attack

Neurological

Epilepsy

Stroke history

Parkinson's disease

Metabolic / Endocrine

Type 1 Diabetes

Type 2 Diabetes

Hypoglycaemia (low blood sugar)

Thyroid condition

Respiratory

Asthma

COPD

Sleep apnoea

Other

Chronic kidney disease

Liver disease

Severe anaphylaxis risk

Pregnancy

Hearing impaired

Visually impaired

Other conditions not listed

Separate multiple entries with a comma

Emergency contacts

Contact 1

Name

Relationship

Phone number

Contact 2 (optional)

Name

Relationship

Phone number

Your contact details

Person placing the order — may differ from card holder. We use these details to send your payment link and delivery updates.

Full name

WhatsApp / phone number

Email address

Delivery address

Where should we post the card to?

Street address

Suburb

City

Postal code

Delivery notes (optional)

Card payload preview

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Your information is stored securely and only used to produce your emergency medical ID card. We will contact you with payment details after registration.

Registration received

We will be in touch shortly with payment details.
Once paid your card will be written and posted to you.