Vial Of Life Medical Information Form - Valley Park Fire District Page 2
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Vial of Life - Medical Information Form
Primary Insurance Information:
Insurance Company: _________________________________________________________________
For assistance completing this form or to ob-
Member ID: _____________________________________ Group # ___________________________
tain additional copies, contact the Valley Park
Medicare/Medicaid Number: _________________________________
Fire Protection District at (636) 225-4288 or
Social Security Number: _____________________________
on the web at
Secondary Insurance Information:
(if applicable)
Date Completed: ____________________
Insurance Company: _________________________________________________________________
Please review and update every 6 months
Personal Information
Member ID: _____________________________________ Group # ___________________________
Name: ________________________________________ DOB: _______/_______/_______
Advanced Directives or Other Special Health Care Considerations
Address: _______________________________________ Phone: _____________________
(If you answer yes to any of the following please include copies of these important documents in
your Vial of Life)
City: ___________________________________ State: __________ Zip: _______________
YES
NO
Do you have a living will?
YES
NO
Do you have a Prehospital DNR (do not resuscitate)
Primary Language: _____________________________ Religion: ______________________
YES
NO
Do you have a Durable Power of Attorney?
Clergy Name and Number: _____________________________________________________
Have you consented to organ donation?
YES
NO
Do you have a history of cardiac (heart) problems?
YES
NO
Emergency Contact Information
If you answered “yes” to the last question please include a copy of your last elec-
Name: _______________________________________ Phone: ______________________
trocardiogram (EKG) from your cardiologist’s office.
Relationship: ________________________________________________________________
Medical Specialist
Alternate Emergency Contact Information
_______________________________
_________________
Physician name:
Phone:
Name: _______________________________________ Phone: ______________________
Medical specialty: _____________________________________
Relationship: ________________________________________________________________
Medical Specialist
Primary Medical Physician
(List Specialists on the back page)
_______________________________
_________________
Physician name:
Phone:
_______________________________
_______________
Physician name:
Phone:
Medical specialty: _____________________________________
_________________________________
Hospital Preference:
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