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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, car, or work. Be sure to update the information often.

    Also, make copies for nonresident 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 two 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. Newer smartphones have apps that you can download to make this information easier to access. Don't rely on your smartphone however, as it may be out of power, overlooked, or not with you at the time. It is still critical to have additional copies of this form.

    Emergency telephone numbers

    9-1-1 (nine, one, one)

    Emergency transport system
    (if the 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                                                                                                    

    Healthcare provider's name and telephone

    Hospital emergency room

    Police

    Fire

    Other

    This information is for

    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 medicines

     

     

     

     

     

    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: Fraser, Marianne, MSN, RN
    Online Medical Reviewer: Perez, Eric, MD
    Date Last Reviewed: 3/1/2018
    © 2000-2020 The StayWell Company, LLC. 800 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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