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Emergency Information Form

In an emergency, it's easy to forget even the most well-known information. That is why it's vital for you to fill out the information in this form for each person in your home. Then give copies to each person in your household. And post all copies in easy-to-find places in your home, car, or workplace. Update the information often.

Also make copies for nonresident relatives, babysitters, caretakers, neighbors, teachers—anyone who has contact with you, or who is sometimes responsible for your children. And make copies for any adults in your home who have a disability or who are older.

If you own a smartphone, put 2 different contacts in your phone under ICE for "in case of emergency." Then the emergency room staff can call your contacts if you're not able to 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. But don't rely on your smartphone. It may be out of power, overlooked, or not with you at the time. It's still vital to have additional copies of this form.

Emergency phone numbers

911

Or use the number for your local emergency transport system (if the 911system isn't available in your area):

_____________________________________________________________

Post the poison control center phone number by every phone 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 on:                                                                      

Weight

at last physical on:

Home address

Directions to home

Home phone/cellphone

Allergies

Health conditions

Current medicines

Emergency contacts

Contact person #1                                                                           

 

 

 

 

Name

Relationship

Work or home address

Phone:

Home                                      

Work                                             

Contact person #2

Name

Relationship

Work or home address

Telephone

Home

Work

Contact person #3

Name

Relationship

Work or home address

Phone

Home

Work

Additional instructions

Online Medical Reviewer: Eric Perez MD
Online Medical Reviewer: Maryann Foley RN BSN
Online Medical Reviewer: Rita Sather RN
Date Last Reviewed: 12/1/2020
© 2000-2021 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.