Fillable Emergency Information Form printable pdf download

Emergency Information Form

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EMERGENCY INFORMATION FORM

DATE: ___________________

NAME: ________________________________________________

PLEASE LIST THE NAME OF THE DOCTOR TO CONTACT IN CASE OF AN

EMERGENCY:

NAME: ___________________________PHONE: ________________________

PLEASE LIST THREE FAMILY MEMBERS AND/OR FRIENDS TO CONTACT IN

THE CASE OF AN EMERGENCY:

(In preferential order)

NAME: ___________________________ PHONE: _______________________

IN THE EVENT THAT YOU ARE INCAPACITATED, WE WILL CALL FOR AN

AMBULANCE AND TAKE YOU TO THE NEAREST HOSPITAL. AT THE SAME

TIME WE WILL CALL YOUR DOCTOR AND AT LEAST ONE PERSON LISTED

ABOVE.

IF THERE IS ANYTHING IMPORTANT THAT SHOULD BE RELATED TO THE

EMERGENCY MEDICAL TECHNICIANS, PLEASE LIST THESE THINGS ON A

SHEET OF PAPER, SEAL IT IN AN ENVELOPE, PUT YOUR NAME ON THE

OUTSIDE, AND WE WILL PUT IT IN YOUR FILE FOR SAFEKEEPING. THE

ENVELOPE WILL BE TURNED OVER TO THE EMT TO READ SO THAT YOU

CAN GET THE BEST, MOST ACCURATE MEDICAL ATTENTION. (List what

medication you are allergic to, what prescription drugs you are taking, diabetes, etc. –

anything you can think of that you would need for them to know.)

________________________________

YOUR SIGNATURE

Emergency Information Form

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