Create Autism Identification Card
Note: None of the information is stored on this Website.  The information is discarded after the card print page is displayed.

Name:

First: Last: Middle Initial:

Date of Birth (format mm/dd/yyyy ):

Address:

Street:

City: , State: ZipCode:

Primary Phone Number: Secondary Phone Number:

Email Address:

Emergency Contacts:

First: Last: Relationship:

Primary Phone Number: Secondary Phone Number:

First: Last: Relationship:

Primary Phone Number: Secondary Phone Number:

Primary Doctor:

First: Last: Phone:

Secondary Doctor:

First: Last: Phone:

Medical Conditions:

Condition 1:

Condition 2:

Condition 3:

Condition 4:

Condition 5:

Condition 6:

Medications:

Drug: Dosage: When Taken:

Drug: Dosage: When Taken:

Drug: Dosage: When Taken:

Drug: Dosage: When Taken:

Drug: Dosage: When Taken:

Drug: Dosage: When Taken:

Allergies - Other Information:

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If the cards look too big or if the text seems out of place, you may have to adjust your browser's text size.   This can be done by clicking on, "View," then choosing "Text Size" in the drop down menu, and then selecting the appropriate size.   You can then go back to change the text size back to the original setting after you print the cards.

If you want to configure, compile, and use this cgi program on your own website, the source is available and can be found here.