Emergency Information Sheet

One-page reference for 911, ER, and family. Post on the fridge.

Keep one copy near the refrigerator and one in the caregiver binder.

The person receiving care

Full name

Home address

Date of birth

Contact 1 — name

Contact 1 — relationship

Contact 1 — phone

Contact 2 — name

Contact 2 — relationship

Contact 2 — phone

Primary physician

Physician phone

Preferred hospital

Pharmacy

Pharmacy phone

Allergies

Current diagnoses

Critical medications (with doses)

Advance directive / code status is kept at

Primary insurance

Evacuation plan

Pets or dependents needing care

Important instructions