Yellow Dot Kit Order Form

During an emergency on the road or at home, time can be critical.

Use this form to get your free Yellow Dot Kit. Each kit has a medical information form, envelope, and car sticker.

The Yellow Dot Program helps first responders get your medical information fast. When they see the Yellow Dot sticker on your car, they know to look for the yellow envelope. The medical information form in the envelope helps them care for you quickly.

The Yellow Dot Program is free for Vermonters!

If you need Emergency Medical Form, click here.

If you are looking for a home-based kit, visit Medical Go Bag Information | Vermont Department of Health.

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1. Are you ordering Yellow Dot kits for an organization or for a family/individual? (select all that apply) *This question is required.

Family/individuals
Organization
Something else- Write In Please enter an 'other' value for this selection.

2. Please provide your contact information.

First Name *This question is required.

Last Name *This question is required.

Organization Name (if applicable)

Email Address *This question is required. This question requires a valid email address.

3. Please provide your mailing address to send your order. *This question is required.

Mailing Address including Apt/Suite/Office. We cannot mail to P.O. boxes. *This question is required.

City *This question is required.

State *This question is required.

Zip *This question is required.

County