Food Allergy & Anaphylaxis Emergency Care Plan Form Page 2
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1
2EPIPEN
(EPINEPHRINE) AUTO-INJECTOR DIRECTIONS
®
2
1. Remove the EpiPen Auto-Injector from the plastic carrying case.
2. Pull off the blue safety release cap.
3. Swing and firmly push orange tip against mid-outer thigh.
4. Hold for approximately 10 seconds.
4
5. Remove and massage the area for 10 seconds.
ADRENACLICK
/ADRENACLICK
GENERIC DIRECTIONS
®
®
1. Remove the outer case.
2
3
2. Remove grey caps labeled “1” and “2”.
3. Place red rounded tip against mid-outer thigh.
4. Press down hard until needle penetrates.
5. Hold for 10 seconds. Remove from thigh.
OTHER DIRECTIONS/INFORMATION (may self-carry epinephrine, may self-administer epinephrine, etc.):
Treat the person before calling emergency contacts. The first signs of a reaction can be mild, but symptoms can get worse quickly.
EMERGENCY CONTACTS — CALL 911
OTHER EMERGENCY CONTACTS
NAME/RELATIONSHIP: __________________________________________________________________
RESCUE SQUAD: ______________________________________________________________________
PHONE: ______________________________________________________________________________
DOCTOR: _________________________________________________ PHONE: ____________________
NAME/RELATIONSHIP: __________________________________________________________________
PARENT/GUARDIAN: ______________________________________ PHONE: ____________________
PHONE: _______________________________________________________________________________
PARENT/GUARDIAN AUTHORIZATION SIGNATURE
DATE
FORM PROVIDED COURTESY OF FOOD ALLERGY RESEARCH & EDUCATION (FARE) ( ) 3/2016
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