Medical ID Bracelet Request Form

Bracelets from Sticky J are currently only available to individuals in the following countries: United States, Australia, Canada, New Zealand, Austria, Barbados, Denmark, Finland, France, Germany, Ireland, Israel, Italy, Jamaica, Japan, Mexico, Netherlands, Norway, Puerto Rico, South Africa, Sweden, Switzerland, and the United Kingdom. Currently we can only accept orders to these countries.

Submitter Information

First Name

Last Name

Please double check your email for accuracy so we can contact you about your order.

Phone

Mailing Address Line 1

Mailing Address Line 2

Country

Postal Code

City

Provinces

State/Province

State

How are you connected to the VEDS community?

My/their diagnosis is:

Medical Specialty

Bracelet Styles

Style 1: Stainless Steel Medical ID Bracelet
(See full details from Sticky J)

Style 2: Sport Strap Medical Alert Bracelet for Kids/Adults
(See full details from Sticky J)

sport strap medical alert bracelet for kids or adults in multiple colors

Style 3: Adjustable Black Polyester Medical ID Bracelet
(See full details from Sticky J)

Bracelet Style

Stainless Steel Bracelet Size

Sport Strap Bracelet Size

Sport Strap Bracelet Color

Sample Bracelet Language

Example Bracelet:

Jane Smith

VEDS: Artery & AoD

Organ rupture,

PTX/HTX, CCSF

ICE: 123-456-7890

No: Penicillin

Prefilled fields (Cannot be changed):

VEDS: Artery & AoD

Organ rupture,

PTX/HTX, CCSF

Fillable Fields

Name

18 character limit

ICE (In Case of Emergency)

phone number only

Allergies

If any or NKA (No Known Allergies). 18 character limit

Extra Lines (If Necessary)

If you need more space for your allergies or additional contact there are up to 6 additional lines available for engraving on the back of the bracelet. We will cover the cost.

Additional Line(s)

Limited to 18 Characters and 6 lines