| Emergency Information |
PERSONAL INFORMATION
| First Name: |
|
Sally |
| Middle Name: |
|
Sample |
| Last Name: |
|
Customer |
| Address1: |
|
123 Any Street |
| Address2: |
|
|
| City: |
|
Springfield |
| State: |
|
MO |
| Zip: |
|
12345-4321 |
| Country: |
|
United States |
|
 |
HEALTH INSURANCE DETAILS |
My Health Insurance is with |
Acme Insurance Ltd |
Group/Plan number |
1234567 |
Provider's Phone |
800 555-1212 |
My member ID is |
1231-3213 |
PERSONAL EMERGENCY INFORMATION |
| Height |
65 inches |
Weight |
120 lbs |
| Hair Color |
Brown |
Eye Color |
Brown |
| Date of birth |
02-29-1970
|
Blood Group |
A POS |
| Sex |
Male |
Skin Tone |
Dark complexion |
| Identifying marks and features |
Surgical scars left knee. |
|
| Eye Glasess |
Yes |
Contact Lens |
No |
| False Teeth |
No |
Pacemaker |
Yes |
PHYSICIAN INFORMATION |
My Doctor |
Dr. Ima Quack |
Phone |
(123) 321-5976 |
Speciality |
General Practice |
|
|
| |
| My Doctor |
Dr. William Perscribe |
Phone |
(123) 321-8926 |
Speciality |
ENT |
|
|
| |
PASSPORT INFORMATION |
Type |
USA |
Country/Code |
123 |
Passport Number |
1325551212 |
Place of Birth |
Customer |
Surname (Last Name) |
Sally Sample |
Given Names |
Springfield, MO |
Date Issued |
30th May , 1999 |
Expiration Date |
29th May 2009 |
Where Issued |
Chicago, IL |
|
PRESCRIPTION INFORMATION |
Prescription |
Lipitor 40 Meg (daily) |
RX Number |
RX237840982 |
| Where Filled? |
Walgreens, 321 Smith St, Springfield, MO (123) 321-4921 |
|
|
| |
Prescription |
Zantex |
RX Number |
over the counter |
| Where Filled? |
Walgreens, 321 Smith St, Springfield, MO (123) 321-4921 |
|
|
| |
Prescription |
Desmopressin Acetate Nasel Solution |
RX Number |
0987987768 |
| Where Filled? |
Walgreens, 321 Smith St, Springfield, MO (123) 321-4921 |
|
|
| |
EMERGENCY CONTACT INFORMATION |
|
Business |
|
Phone |
|
| |
Emergency Contact |
Bert Customer |
Relationship |
Spouse |
| Phone |
(123) 123-4567 |
CellPhone/Pager |
BurtSample@bs747.com |
| |
| Emergency Contact |
Bill Henderson |
Relationship |
Friend |
Phone |
(123) 876-1953 |
CellPhone/Pager |
(123) 876-1234 |
| |
| Emergency Contact |
Martha Customer |
Relationship |
Mother |
| Phone |
(123) 321-2958 |
CellPhone/Pager |
|
ALLERGIC- DO NOT GIVE |
Allergic To |
Peanuts |
Reaction |
rash, shortness of breath
|
| Allergic To |
High doctor Bills |
Reaction |
rash, shortness of breath. |
Allergic To |
Taxes |
Reaction |
Extreme irritation
|
| VACCINATIONS - YEAR OF LAST VACCINATION |
| Tetanus/diphtheria |
1987 |
Pneumococcal Vaccine |
Dont Know |
| Flu Vaccine |
2002 |
Measles,Mumps,Rubella |
1978 |
| Polio |
1952 |
Varicella(Chickenpox) |
Never |
| Hepatitis- A |
1997 |
Yellow Fever |
1978 |
| Hepatitis-B 1 shot |
1997 |
Hepatitis-B 2nd shot |
1999 |
| Cholera |
2003 |
Meningitis |
2002 |
| Typhoid |
2002 |
|
|
| MEDICAL POWER OF ATTORNEY |
| Person Designated |
EdwinCustomer |
Relationship |
Brother |
| Telephone |
(123) 321-5926 |
CellPhone/Pager |
(123) 321-4567 |
instructions for organ donations can be found at |
I do not wish to make any organ donations |
| LIVING WILL |
| I have a Living Will and the Executor is |
Atty John Suem |
Phone |
(123) 123-4567 |
| Business Phone |
(123) 321-5930 |
Cellphone/pager |
(123) 321-5930 |
| Email |
Suem@bs747.com |
|
|
| ADDITIONAL INFORMATION |
| Do you want extraordinary measures used to keep you alive? |
NO! |
| Other important information in an emergency |
In case I am injured and in a vegatative state with little or no possibiliy of recovery, I wish to be allowed to die. |
|