new order form stickers | Stop and Know

Tag : What would you like to name this order? This is usually the first name of who the item will be for. Make it something you'll remember, it will be needed to locate your order if you need assistance or future QR code updates. (Important: If you've previously ordered other products for this person, please tag this order with the SAME name.)*

Your First Name*

Your Last name*

Your email (Important: If you've placed previous orders with us, please use same email)*

Shipping Street Address*

City*

State*

Zip Code*

QR sticker type:*

Without Alert

With Alert- black arrowed box at top of QR code- select below

Alert Statement (leave blank if "without alert" selected)

Autism Alert

Dementia Alert

Epilepsy Alert

Medication Alert

Deaf Person Alert

Nonverbal Alert

Mental Health Alert

Cardiac Alert

Diabetic Alert

Parkinson's Alert

Prior Stroke Alert

Other (type in box below) 20 character max including spaces

Other

QR CODE- Emergency Contact (first name only)*

QR CODE- Relationship (mother, father, caregiver, sibling etc...)*

QR CODE- Phone of emergency contact (this should be a number they are reachable at all times. Cell phones are best.)*

QR CODE- Does the person this card is for wish to provide a current medication list?*

Yes

No

Include prescription and over-the-counter drugs and supplements. List medication name, dosage, and frequency, if known. Please ensure accuracy as we will enter this information exactly as it is given to us. Press enter to put each medication on its own line.

QR CODE- Does this person this card is for have any allergies they wish to disclose? *

Yes

No

If yes, enter here

QR CODE- Does the person this card is for wish to share anything else with a first responder or anyone helping them?*

Yes

No

If yes, enter here

Disclosure and Confirmation *

I confirm the information I've provided is accurate to the best of my knowledge. I confirm that I am the person for whom this order is placed or I am authorized to place this order on their behalf. I understand that Stop and Know is not responsible for any errors or inaccuracies provided by me on this order form, including but not limited to, any diagnosis, behavior information, allergies, medications and/or their spellings and dosage. I understand I may request any information embedded in a QR code on the resulting KnowID product be updated free of charge by completing the appropriate update request form. Physical replacement of any KnowID product will incur a cost at the currently published replacement cost which may be found in the FAQ page of this website. I can email hello@stopandknow.org if I need assistance.

Email