Emergency information sheet (fill-in form)
One page with the information paramedics and hospitals need. Keep a copy on the fridge and in the car.
Full name: ____________________________________________
Date of birth: ____________________________________________
Address: ____________________________________________
Emergency contact 1 (name, phone): ____________________________________________
Emergency contact 2 (name, phone): ____________________________________________
Health care surrogate / POA (name, phone): ____________________________________________
Primary doctor (name, phone): ____________________________________________
Preferred hospital: ____________________________________________
Allergies: ____________________________________________
Conditions the responder should know: ____________________________________________
Conditions the responder should know: ____________________________________________
Advance directive / DNR on file? Where kept: ____________________________________________
Mobility or hearing/vision needs: ____________________________________________
Pets at home and who to call: ____________________________________________
General information only, not medical, legal or financial advice. Programs and amounts change; confirm with the official source or a qualified professional.