Medical Alert Bracelet Request Form

Please fill out the form below to request a Responder PHR with Medical Alert Bracelet and Keychain. Upon submitting the request form below, we will ship out your device in the order your request was received. Please email ResponderPHR@curesma.org with any questions. Also, please note we are unable to ship to P.O. boxes.

Package Includes:

(1) adjustable 5.5” 8.5” unisex medical alert bracelet.
(1) medical alert keychain.
(2) engraved acrylic plates which contains the URL access and a unique 8-digit member ID number. (This information is what allows a medical responder access to one’s Personal Health Record online)
(2) custom engraved acrylic plates which contains the members most critical medical information to be easily read in any emergency.
(1) Emergency Medical Card which can be completed, updated, edited, and printed either online or manually entered.

I acknowledge I have read through the eligibility criteria below and meet all of the requirements.

Eligibility Criteria:

Must have confirmed SMA diagnosis.
Must live within the United States.
A legal guardian can request device on behalf of their affected child if individual with SMA is under the age of 18.

*This question is required.

Are you affected by SMA or are you filling out this request on behalf of a person with SMA? *This question is required.