Emergency MedicalInformation



Emergency Medical

Information

Name:       Birthdate (include year):     

Person to notify in an emergency:

Name:       Phone:      

Name:       Phone:      

Physician:       Phone:      

Allergies:      

Medical Conditions:      

Medications:      

Blood Type:      

Date Completed:4/25/2014[pic]9/16/2005 City and County of Honolulu

Emergency Medical Services

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Post it on your refrigerator or near your telephone in case of an emergency.

Fill out one card per family member. Post completed forms on your refrigerator or near your telephone in case of emergency.

|Emergency Medical |Emergency Medical |Emergency Medical |

|Information |Information |Information |

|Name:       |Name:       |Name:       |

|Birthdate       |Birthdate       |Birthdate       |

|(include year): |(include year): |(include year): |

|Person to notify in an emergency: |Person to notify in an emergency: |Person to notify in an emergency: |

|Name:       Phone:       |Name:       Phone:       |Name:       Phone:       |

|Name:       Phone:       |Name:       Phone:       |Name:       Phone:       |

|Physician:       Phone:       |Physician:       Phone:       |Physician:       Phone:       |

|Allergies:       |Allergies:       |Allergies:       |

|Medical Conditions:       |Medical Conditions:       |Medical Conditions:       |

|Medications:       |Medications:       |Medications:       |

|Blood Type:       |Blood Type:       |Blood Type:       |

|City and County of Honolulu |City and County of Honolulu |City and County of Honolulu |

|Date Completed: 4/25/2014[pic]9/16/2005 Emergency Medical Services |Date Completed: 4/25/2014[pic]9/16/2005 Emergency Medical Services |Date Completed: 4/25/2014[pic]9/16/2005 Emergency Medical Services |

|Emergency Medical |Emergency Medical |Emergency Medical |

|Information |Information |Information |

|Name:       |Name:       |Name:       |

|Birthdate       |Birthdate       |Birthdate       |

|(include year): |(include year): |(include year): |

|Person to notify in an emergency: |Person to notify in an emergency: |Person to notify in an emergency: |

|Name:       Phone:       |Name:       Phone:       |Name:       Phone:       |

|Name:       Phone:       |Name:       Phone:       |Name:       Phone:       |

|Physician:       Phone:       |Physician:       Phone:       |Physician:       Phone:       |

|Allergies:       |Allergies:       |Allergies:       |

|Medical Conditions:       |Medical Conditions:       |Medical Conditions:       |

|Medications:       |Medications:       |Medications:       |

|Blood Type:       |Blood Type:       |Blood Type:       |

|City and County of Honolulu |City and County of Honolulu |City and County of Honolulu |

|Date Completed: 4/25/2014[pic]9/16/2005 Emergency Medical Services |Date Completed: 4/25/2014[pic]9/16/2005 Emergency Medical Services |Date Completed: 4/25/2014[pic]9/16/2005 Emergency Medical Services |

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