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.