THIS IS SAMPLE INFORMATION ONLY! DO NOT USE FOR EMERGENCIES!
This is the information that will be available for rapid lookup by Doctors, hospitals and other care givers if you have a medical emergency or are involved in an accident.
PERSONAL INFO
First Name:
Sally
Middle Name:
Sample
Last Name:
Customer
City:
Springfield
State:
MO
Zip:
12345-4321
Your picture can go here. Use the upload feature on the member page.
My Health Insurance is with
Group / Plan number
Provider's Phone
My member ID is
PERSONAL EMERGENCY INFO
Height
Weight
Hair Color
Eye Color
Date of birth
Blood Group
Sex
Male
Female
Skin Tone
Identifying marks and features
Eye Glasess
Yes
No
Contact Lens
Yes
No
False Teeth
Yes
No
Pacemaker
Yes
No
PASSPORT INFORMATION
Type
Country / Code
Passport Number
Place of Birth
Surname (Last Name)
Given Names
Date Issued
Expiration Date
Where Issued
PHYSICIAN INFO
My Doctor
Phone
Speciality
My Doctor
Phone
Speciality
My Doctor
Phone
Speciality
My Doctor
Phone
Speciality
My Doctor
Phone
Speciality
PRESCRIPTIONS AND OVER THE COUNTER MEDICATIONS
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
Prescription
RX Number
Where Filled?
EMERGENCY CONTACT INFO
Emergency Contact
Relationship
Phone
Business/Cell/ Pager
Emergency Contact
Relationship
Phone
Business/Cell/ Pager
Emergency Contact
Relationship
Phone
Business/Cell/ Pager
ALLERGIC- DO NOT GIVE
Allergic To
Reaction
Allergic To
Reaction
Allergic To
Reaction
VACCINATIONS - YEAR OF LAST VACCINATION
Tetanus/diphtheria
Pneumococcal Vaccine
Flu Vaccine
Measles,Mumps,Rubella
Polio
Varicella (Chickenpox)
Hepatitis-A
Yellow Fever
Hepatitis-B 1 shot
Hepatitis-B 2nd shot
Cholera
Meningitis
Typhoid
MEDICAL POWER OF ATTORNEY
Person Designated
Relationship
Telephone
Business/Cell/ Pager
I do not wish to make any organ donations:
OR instructions for organ donations can be found at
LIVING WILL
I have a Living Will and the Executor is
Phone
Business Phone
Cell/ Pager
Email
EXTRAORDINARY MEASURES
Do you want extraordinary measures used to keep you alive?
OTHER IMPORTANT INFORMATION IN CASE OF AN ACCIDENT, EMERGENCY, AND PERTINENT MEDICAL HISTORY
Your picture can go here. Use the upload feature on the member page.