AVBI Medic Alert Tag & ID Card Application


If you are a servicemember / veteran who suffered a medically documented brain injury, and would like to have an AVBI medical alert Dog Tag and ID card mailed to you, please fill out the following. Applications will only be accepted if submitted by the servicemember / veteran, a member of their immediate family, or an authorized caseworker/medical professional.
Fields marked with an *are required.

Veterans First Name:*
Veterans Last Name:*
Veterans Address:* City:*
State:* Zip Code:*
Phone number:* E-mail:*

(Veterans/Point of Contact Phone #)
(Veterans/Point of Contact Email) 
Branch of Service:* Military Status:*

(Active Duty, Retired, Discharged)
Type of Injury(s):*
Date of Injury:* Seizures?*
Service Connected?* Severity of BI:*
Do you need additional assistance or would you like us to contact you? 
(Please provide any additional information as to how we might help you in the area below.)

Comments or Message:

If other than the Veteran is filling out this application; please provide us with your information.
First Name:
Last Name:
E-mail: Relationship:
Telephone Number:

Comments or Message:

By clicking the "Submit Application" button you are sending us information you have provided. This submission authorizes American Veterans with Brain Injuries, Inc. (AVBI) to contact you in pursuit of your request. Additional information or medical documentation may be requested before we fulfill your request. Your information is safe and will be retained by AVBI; No information provided will be sold, transferred or distributed to a third party.