Vial Of Life Form Page 2
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1
2List major surgeries you have had
Date
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Do you have:
A “Living will” or advanced directive?
A North Carolina “Do Not Resuscitate” order signed by your doctor?
Is there any other information that would help EMS or hospital personnel in providing your
emergency medical care?
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Persons to contact in an emergency:
Name _______________________________________ Relationship __________________
Address ___________________________________________________________________
Day phone _________________________Night phone ______________________________
Name _______________________________________ Relationship ___________________
Address ___________________________________________________________________
Day phone__________________________ Night phone _____________________________
Name _______________________________________ Relationship ___________________
Address ___________________________________________________________________
Day phone _________________________Night phone ______________________________
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