Bestelformulier

Dear Sir/Madam,

We have a waiting time of about 3 weeks. Please, keep this in mind when ordering! Our apologies! The waiting time is getting shorter!

We recommend you to discuss the wish of no resuscitation with the doctor and with your loved ones first.

Further we recommend good information prior to purchasing on the possible consequences of wearing this DNR-pendant.

For example, it is also important that your not resuscitate wish is included in your medical file. If you order this pendant for someone else, you need to be authorized by that person.

Our DNR-pendants are neutral. DNR-text, name, date of birth, signature and photo are engraved on the pendant, so it is very complete and official. But it is best to check the local law and legislation in your state first, because there may be variations in DNR-regulation. We can customize your pendant, so it will be legitimate in your state/country.

You can make your choice by checking or unchecking the boxes and through the ''drop-down menus'' Always check that you have chosen the right choice checkmarks! Product images are at the bottom of this form and on the website.

Rectangular pendant € 19.50 EUR

Material / color

Silicone edge to rectangular pendant € 2.00 EUR

Color

Round pendant € 19.50 EUR

Color / matarial
Item subtotal: € 0.00 EUR

Necklace € 2.50 EUR

Color / type

DNR-Bracelet, nylon (blue or red) € 15.00 EUR

Quantity Color

Shipping costs € 1.75 EUR

Shipping options

Total € 0.00 EUR

Last name + initials (to be engraved) *

Date of birth (to be engraved) *

Month Day Year

For whom is this pendant for? *

Details:

If you order a pendant for someone else, then the pendant needs to have a 'passport photo' (with the exception of mat titanium pendants) and signature. If you do NOT wish a photograph and signature to be engraved on the pendant, then you need to include a Declaration of intent or physicians statement.

Please note: Without a photograph and signature, there is a potential risk that people will ignore the pendant.

The data can be scanned and emailed or uploaded below, or as a copy be sent to our postal address. Upload below is the fastest way and is preferred! (ask help, if needed)

Only if applicable: Upload Declaration of intent or physicians statement below

Mr/Mrs *

Last name and initials *

Street name *

House number *

Postal code *

Residence / City *

E-mail

Phone number

Area code Number

This text is a standard text.The text on the front side is:.
'DO NOT RESUSCITATE'

The text on the backside is also standard, but can be adapted. The standard text is:

' I FORBID ANYONE, UNDER ANY CIRCUMSTANCES TO APPLY ANY FORM OF CPR ON ME '

Only if you prefer a custom text, you can create your own text below, Please mention this first: ' text front or back '.

Agreement with standard text front and back. *

If you prefer another text, please give the desired engraved text for the front-/backside in the box below. This is at your own risk.

We engrave your photo identification (with the exception of the mat titanium pendants) and signature on the pendant. This meets the official requirements of a will. To check your personal data you should therefore upload a scan of your ID. You should always protect your social security number. You can upload the signature, passport photo and ID via this form. See "upload" buttons below. This can be a picture, or scan. This is the fastest way. If necessary, someone in your area may be able to assist you with the upload. However, should this not succeed, you can send the files by email to: info@kado-foto.nl or by mail.

After 30 days your credentials will be erased from our database. We will be very careful and confidential with your information!

Please note: With the delivery of your signature gives us (Kado-foto): 1. officially the command to create and your Do-Not-Resuscitate pendant. 2. the signature for engraving on your Do-Not-Resuscitate pendant. 3. that you are well informed about the consequences of wearing a Do-Not-Resuscitate pendant. For this you can go to your family doctor. We can also provide and refer you to various sources of information. See also our website.

I will send passport photograph, signature and copy of ID via: *

If you don't want an engraved photo and signature on the pendant, this is at your own risk! (see explanation below) Because it is possible that for first responders, it might be less clear that the pendant belongs to you. This choice is free, but the penny does not meet the requirements of a Do-Not-Resuscitate pendant, because of the lack of the signature. As a result, there is a possibility that first responders will start with resuscitation.

Ordering by post always takes longer, because the processing of the data takes more time. The fastest way, with the shortest lead time is via upload (If this does not work, then we can guide you through this by email, or you can ask people from your vicinity for help with this).

Upload with this button your PHOTO IDENTIFICATION from you computer to us (preferably as a JPEG or JPG file)

Upload with this button your signature from your computer to us (preferably as a JPEG or JPG file)

Signature: you can also put in the box below your signature/drawing. Please above the line!

Clear

Upload your copy of your ID to us from your computer, with the upload button below. (preferably as a JPEG or JPG file)

You can drop any additions, comments or details here.

I have checked the order and give this order, where I will meet the payment immediately. *

The total amount in Euro's you can find out by checking your choices on this order form, after which you can see the total amount. If we receive your order, we will give you the total amount in USD or GBP. (based on daily exchange rate) The total amount can be paid via bank transfer, in advance to:

Kado-foto

IBAN/SEPA account number: NL88 KNAB 0283 7125 54

Swift-code: KNABNL2H

Please stating: your last name + order No. (see top of form of confirmation email!) + name of carrier of the DNR-pendant.

Thanks in advance for your payment!

Press the '' SUBMIT ORDER button ' ' below 1 time, only then your order will be sent. You need to have completed all required fields above! Note: Please make sure all the required check marks are checked! If you need assistence, please send us an email at: info@kado-foto.nl so we can help you. If you do not receive an email confirmation within 24 hours, then the order is probably not placed correctly. Please email us, or try to place an order again, where everything is filled out completely.

Orderform Do-Not-Resuscitate pendant (neutral)

Personal data for DNR-pendant:

Address data for shipping

Text on backside of pendant

Passport photograph, signature, ID-check

Additions/comments:

Payment