Emergency Medical Information Sheet

This form is strictly voluntary. There is no intention to obtain personal information unless a medical emergency arises.
If you choose to participate, complete this form and place it in a envelope. Seal the envelope and mark the outside
"Emergency Medical Information of _____________________" (Insert your name)
You may claim the envelope upon departure. Unclaimed envelopes will be shredded un-opened.

Name________________________________________________________________________________

Date of Birth (month/day/year)_____________________________________________ Age___________

Emergency Contacts

Name_________________________________________________________________________________

Home Phone ____________________Work Phone __________________Relationship________________

Name________________________________________________________________________________

Home Phone ____________________Work Phone __________________Relationship________________

Physician(s)

Name_________________________________________________ Phone _________________________

Does your physician need to be notified immediately if you are transported to the hospital? __Yes __ No

Does your insurance require you to go to a specific hospital in non-life threatening emergencies? __Yes __No

Allergies to medication___________________________________________________________________

Major Medical history, operations, current problems, illnesses, etc.

_____________________________________________________________________________________

[ ] More on reverse side

Medications

Name of Medication Dosage Frequency

_____________________________________________________________________________________

Other medical information

_____________________________________________________________________________________