Please print out this page, complete it and place it inside your phone book for quick reference during an emergency.  Print and complete a form for each person living with you.

Name
  
Social Security Number
  
Address

 

  
Telephone
  
Date of Birth
  
Health Care Plan
  
Doctor's Name
  
Doctor's Phone Number
  
Allergies
  
Medications
  
Major Illnesses/Injuries
  
Emergency Contact & Phone
  
Medic Alert #:
  
Advanced Directive (Living Will, No CPR, etc.) Where is the information located?
  

For information on how to become part of Medic Alert Medical Information Systems, contact 1.800.825.3785.