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Emergency Form

Name: _______________________ _____________________ ______________ Birth date: ____/____/____ Last Name First Name M.I.

Address: ___________________________________________________ Apt. #: ________________________

City: __________________________________________ State/Zip: __________________________________

Home Phone: ______________________________ Mobile Phone: ___________________________________

Social Security Number: ______ - ______ - ______ Driver's License/ State ID #:__________________________

Hair Color: _________________ Eye Color: __________________ Height: ____________ Weight: _________

Emergency Contact Information

Name: _________________________________________ Relationship: _______________________________ Mailing Address: ____________________________________________________________________________ Home Phone: __________________________________ Mobile Phone: _______________________________

Name: _________________________________________ Relationship: _______________________________ Mailing Address: ____________________________________________________________________________ Home Phone: __________________________________ Mobile Phone: _______________________________

Insurance Information

Primary Carrier Insurance Carrier: _____________________________ Policy Holder's Name:___________________________ Policy Number: __________________________________ Group Number: _____________________________ Phone Number: __________________________ Pre-Certification Phone: ______________________________

Secondary Carrier (Medicaid, Medicare, etc.) Insurance Carrier: _____________________________ Policy Holder's Name:___________________________ Policy Number: __________________________________ Group Number: _____________________________ Phone Number: __________________________ Pre-Certification Phone: ______________________________

Date Completed:

_____________________

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Medical Information

Primary Care Doctor: _______________________________ City/State: _______________________________ Telephone Number: _____________________________ Emergency Service: ___________________________ Specialty Doctor: ___________________________________ City/State: _______________________________ Telephone Number: _____________________________ Emergency Service: ___________________________ If necessary, transport me to the following hospital: _______________________________________________ Pacemaker: ______ Yes ______ No Eyeglasses: ______ Yes ______ No Contact Lens: ______ Yes ______ No False Teeth: ______ Yes ______ No Birthmarks/Scars: ___________________________________________ Medical Allergies Allergic To: __________________________ Reaction: ________________________________ Allergic To: __________________________ Reaction: ________________________________ Allergic To: __________________________ Reaction: ________________________________ Allergic To: __________________________ Reaction: ________________________________ Current Prescription Medications ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Chronic Medical Conditions (Diabetic I or II, Emphysema, Congestive Heart Failure, etc.) Condition: ____________________________________________ Diagnosed: __________________________ Specialist: ____________________________________________ Condition: ____________________________________________ Diagnosed: __________________________ Specialist: ____________________________________________ Condition: ____________________________________________ Diagnosed: __________________________ Specialist: ____________________________________________ Medical Conditions (Anemia, High Blood Pressure, Hearing Loss, Blind, etc.) Condition: ____________________________________________ Diagnosed: __________________________ Specialist: ____________________________________________ Condition: ____________________________________________ Diagnosed: __________________________ Specialist: ____________________________________________ Condition: ____________________________________________ Diagnosed: __________________________ Specialist: ____________________________________________

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Current Vaccinations (Please enter the year of last vaccination) _______ Tetanus/diphtheria _______ Pneumococcal vaccine _______ Flu vaccine _______ Measles, mumps, rubella

_______ Polio _______ Varicella (chickenpox) _______ Hepatitis A _______ Hepatitis B

Special Instructions: ( For example: When excited - seizure prone; swallowing difficulties; tends to hyperventilate, etc.) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Living Will: ____ Yes ____ No Do Not Resituate: ____ Yes ____ No Organ Donor ____Yes ____ No Medical Power of Attorney: Person Designated: _________________________________ Telephone Number: _______________________ Mailing Address: ________________________________________ Mobile Number: _____________________

PLEASE FILL OUT IF THIS PERSON IS UNDER AGE 18

I certify that this form is for my child, under age 18. _________ Yes, I grant permission to treat my child in an emergency _________ No, contact me prior to treating my child Parent Name: __________________________________ Emergency Telephone Number: _____________________________________ Signature: _____________________________________