VIAL OF L.I.F.E.
LIFE SAVING INFORMATION FOR EMERGENCIES
I certify that the information on this form is accurate and up-to-date. I also understand that
emergency personnel may rely on this information. I agree not to hold emergency personnel
responsible for inaccurate or out-of-date information.
DATE COMPLETED/UPDATED________________ SIGNATURE_____________________________
Date of Birth:
Social Security Number:
Home Phone: (
Cell Phone: (
Primary Medical Problems:
Previous Medical Problems: (Check all that apply):
Low Blood Pressure
High Blood Pressure
Do you have a pacemaker?
Yes, Model #:_________________ Blood
Allergies to medications (list):
Do you have an Advance Directive?