Clover's Group

Essential Care Information

Faith · Hope · Love · God's Grace

Last updated: ____________

Condensed Guide

Essential Care Information

Identity, emergency info, family and providers — everything the whole team needs.

3 pages · ~25 min · Prints on ≤ 3 Letter pages

CLOVER’S GROUP

Faith · Hope · Love · God’s Grace

Care recipient & caregiver

page 1 / 3

Identity

Preferred name

Legal name

Date of birth

Home address

Phone

Primary language

Preferred hospital

Health & care needs

Primary diagnoses

Allergies

Mobility needs

Communication needs

Cognitive or behavioral considerations

Dietary needs

Faith or spiritual preferences

Primary caregiver

Caregiver's name

Relationship

Last updated

Emergency & household

page 2 / 3

Emergency call

Contact 1 — name

Contact 1 — relationship

Contact 1 — phone

Contact 2 — name

Contact 2 — relationship

Contact 2 — phone

Medical essentials

Current diagnoses

Critical medications (with doses)

Advance directive / code status is kept at

Primary insurance

Primary physician

Physician phone

Pharmacy

Pharmacy phone

Home & household

Evacuation plan

Pets or dependents needing care

Important instructions

Contacts & providers

page 3 / 3

Family, medical, community contacts

Contacts

Contact 1

Name / organization

Role or service (family, doctor, pharmacy, legal, transportation, church, etc.)

Phone

Address

Website

Hours

Preferred contact method

Notes

Contact 2

Name / organization

Role or service (family, doctor, pharmacy, legal, transportation, church, etc.)

Phone

Address

Website

Hours

Preferred contact method

Notes

Contact 3

Name / organization

Role or service (family, doctor, pharmacy, legal, transportation, church, etc.)

Phone

Address

Website

Hours

Preferred contact method

Notes

Contact 4

Name / organization

Role or service (family, doctor, pharmacy, legal, transportation, church, etc.)

Phone

Address

Website

Hours

Preferred contact method

Notes

Contact 5

Name / organization

Role or service (family, doctor, pharmacy, legal, transportation, church, etc.)

Phone

Address

Website

Hours

Preferred contact method

Notes

Contact 6

Name / organization

Role or service (family, doctor, pharmacy, legal, transportation, church, etc.)

Phone

Address

Website

Hours

Preferred contact method

Notes

Medical providers

Providers

Provider 1

Provider name

Specialty

Practice

Phone

Fax

Portal or website

Address

After-hours instructions

Referral requirements

Next visit

Notes

Provider 2

Provider name

Specialty

Practice

Phone

Fax

Portal or website

Address

After-hours instructions

Referral requirements

Next visit

Notes

Provider 3

Provider name

Specialty

Practice

Phone

Fax

Portal or website

Address

After-hours instructions

Referral requirements

Next visit

Notes