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Emergency Information Form

In an emergency, it is easy to "forget" even the most well-known information. That is why it is crucial for you to complete the information in this form for each member of your household. Then, distribute copies to each member of your household. Also, post all copies by each telephone and in easy to find places in your home, automobile, or place of business. Be sure to update the information frequently.

Also, make copies for non-resident relatives, babysitters, caretakers, neighbors, teachers -- anyone who has contact with you or who is periodically responsible for your children (or any disabled or older adults in your home).

If you own a cell phone, put 2 different contacts in your phone under ICE for 'in case of emergency,' so emergency room staff can call your contacts in the event you can not communicate. Examples could be ICE-mom or ICE-husband to identify your contact.

Emergency Telephone Numbers:

9 1 1 (nine, one, one)

Emergency Transport System
(if 9-1-1 system is not available in your area)

                                                                                                                              

Post the poison center telephone number by every telephone in your home. The national, toll-free poison control center locator number is: 800-222-1222.

From here, you will be automatically redirected to the nearest Poison Center in your area.

Poison control                                                                                                    

Physician's name/telephone

Hospital emergency room

Police

Fire

Other

This information is

Person's Full Name                                                                        

Date of birth

Height

at last physical in:                                                                      

Weight

at last physical in:

 

Home Address

Directions to Home

Home Telephone

 

Allergies

 

 

 

 

 

Medical Conditions

 

 

 

 

 

Current Medications

 

 

 

 

 

Emergency Contacts:

Contact Person #1                                                                           

Name

Relationship

Work or Home Address

Telephone:

home                                      

work                                             

 

Contact Person #2

Name

Relationship

Work or Home Address

Telephone:

home

work

 

Contact Person #3

Name

Relationship

Work or Home Address

Telephone:

home

work

 

Additional Instructions:

Online Medical Reviewer: Hanrahan, John, MD
Online Medical Reviewer: Weisbart, Ed, MD
Date Last Reviewed: 4/15/2013
© 2000-2014 The StayWell Company, LLC. 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
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