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                     In Case of An Emergency
A copy of this form, and all attachments, should be visible on your refrigerator, a copy put in the glove compartment of all vehicles, one provided to school for child's records, one provided to your employer for your personal file, and a copy provided to your primary care physician. 
One form should be filled out for each member of your family. Click above if you would like this form in a Word Document suitable forfilling out and printing.
Jean
In Case of An Emergency
 
Date Form Completed: _________ Current Age: ____

INFORMATION IS FOR:

Last Name: _________________________
First Name:
_________________________
Middle Initial:
_______________________
Social Security Number:
____-____-_____
Blood Type: _______
Medications Allergic To: (See Below)

EMERGENCY PHONE NUMBERS (besides 911);

Fire: ________________
Police:
______________
Ambulance:
__________
Hospital:
____________

DIRECTIONS-To provide Emergency Personnel directions to your home:

Subdivision or Condo Association: _______________________
Nearest Intersections:
________________________________
Nearest Major Roads
: _________________________________

OTHER PERSONAL INFORMATION

Date of Birth: ________________
House Number
________________
Street:
________________
City
________________
State
________________ Zip_________________
Home Phone # (
___) ____ - ______
Driver's License #
_______________
Height:
_________ Weight: ________
Hair Color:
_________ Eyes: ________
Pacemaker: ( ) yes ( ) no
Eye Glasses: ( ) yes ( ) no
Contact Lens: ( ) yes ( ) no
False Teeth: ( ) yes ( ) no
Birthmarks or Scars/Where:
________________

PHYSICIAN(s):

Primary Care Doctor___________________
City/State:
__________________________
Telephone Number
___________________
Emergency Service
___________________

Specialist (identify)
City/State:
___________________________

Telephone Number ____________________
Emergency Service
____________________

HOSPITAL(s) -

Name the preferred hospital or one covered by your insurance

If necessary transport me to the following hospital:


________________________________________

INSURANCE:

Primary
Carrier (i.e. Prudential etc)
__________________
Policy #
______________Group #___________
Policy Holder's Name
: _____________________
Phone:
________________________________

Pre-Certification Phone: ___________________

Secondary (Medicaid, Medicare, etc.)
Carrier
__________________________________
Policy #
________________Group #___________
Policy Holder's Name:
_______________________

Phone:
__________________________________

Pre-Certification Phone: _____________________

EMERGENCY CONTACT(s)

Name ____________________________
Relationship to you
_________________
Phone Number
_____________________
Cell Phone/Pager
___________________

Name
____________________________
Relationship to you
_________________
Phone Number
_____________________
Cell Phone/Pager
___________________

OTHER PERTINENT DOCUMENTS/INFORMATION

If applicable, attach document to this sheet

Living Will ( ) yes ( ) no
Do Not Resituate ( ) yes ( ) no
Organ Donor: ( ) yes ( ) no

Medical Power of Attorney:
Person Designated
:_____________________
Telephone Number
_____________________
Cell Phone/Pager #
_____________________

CHRONIC MEDICAL CONDITION(s)

(Identify, i.e. Huntington's Disease, Cancer, Congestive Heart Failure, Diabetic I or II, Emphysema, Epilepsy, Seizures, Kidney or Liver disease etc.)

Condition:
_______________
Diagnosed:
______________
Specialist:
_______________

Condition:
_______________
Diagnosed:
______________
Specialist:
_______________

OTHER MEDICAL CONDITIONS:

(Identify i.e. Hearing Loss, Blind, Anemia, Thyroid Disease, High Blood Pressure, etc.)

Condition:
_______________
Diagnosed:
______________
Specialist:
_______________

Condition:
_______________
Diagnosed:
______________
Specialist:
_______________

VACCINATIONS  -  Year of last vaccination
___Tetanus/diphtheria
___Pneumococcal vaccine
___Flu vaccine
___Measles, mumps, rubella
___Polio
___Varicella (chickenpox)
___Hepatitis A
___Hepatitis B

ALLERGIC TO - DO NOT GIVE:

(list everything i.e. Morphine causes rash, etc.)

Allergic to:
_________________
Reaction:
_________________

Allergic to:
_________________
Reaction:
_________________

Allergic to:
_________________
Reaction:
_________________

SPECIAL INSTRUCTIONS:

Identify i.e.: Keep Calm/Tends To Hyperventilate When Excited-Seizure Prone;

Do Not Use Restraints; Keep Head Elevated/Swallowing Difficulties, etc.
__________________________________
__________________________________
__________________________________
__________________________________

CURRENT PRESCRIPTION MEDICATION(s)
List or use the
Medication Form and say "See Attached"

ADDITIONAL CONTACTS - (To Be Made By Family, Not EMS, I.e. employer, other emergency contacts, funeral homes, clergy, etc.)

Organization:
___________________
Person To Contact
_______________
Telephone No.
__________________

Organization:
___________________
Person To Contact
_______________
Telephone No.
__________________

Organization:
___________________
Person To Contact
_______________
Telephone No. __________________

THIS PERSON IS UNDER AGE 18

This form is for my child, under age 18. Permission is granted to treat my child in an emergency

( ) Yes.   ( ) No, contact me prior to treating.

Parent Name:
_____________________________
Emergency Telephone Number:
_______________

Signature:
________________________________

Email Webmaster ~ Jean E. Miller