Emergency Contact Information

In an emergency, it is easy to "forget" even the most well-known information. That is why it is crucial for you to complete the information in this form for each member of your household. Make sure the contact sheet is kept in a place at your home that is accessible to all members of your famiily. It is also important to keep a copy in your car, place of work, and with you at all times. Be sure to update the information frequently.

Make copies for nonresident relatives, babysitters, caretakers, neighbors, teachers--anyone who has contact with you or who is periodically responsible for your children (or any disabled or elderly persons in your home).

Emergency telephone numbers

9 1 1 (nine, one, one)

Emergency transport system
(if 9-1-1 system is not available in your area)

Post the poison center telephone number by every telephone 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.

Emergency contact information

Poison control:

Police:

Fire:

Ambulance:

Hospital:

Family member information

Name:

Birth Date:

Home phone:

Mobile:

Address:

Height:

Weight:

Allergies:

Medical conditions:

Medications:

Doctor:

Phone:

Name:

Birth Date:

Home phone:

Mobile:

Address:

Height:

Weight:

Allergies:

Medical conditions:

Medications:

Doctor:

Phone:

Name:

Birth Date:

Home phone:

Mobile:

Address:

Height:

Weight:

Allergies:

Medical conditions:

Medications:

Doctor:

Phone:

Name:

Birth Date:

Home phone:

Mobile:

Address:

Height:

Weight:

Allergies:

Medical conditions:

Medications:

Doctor:

Phone:

Online Medical Reviewer: Bass, Pat F. III, MD, MPH
Online Medical Reviewer: Dozier, Tennille, RN, BSN, RDMS
Last Review Date: 03/30/2013
© 2000-2013 Krames StayWell, 780 Township Line Road, Yardley, PA 19067. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.