EmailMe Form - Emergency Medical Information

Emergency Medical Information
By completing this form, I have authorized the use of my health information by First Baptist Church to assist in my care in the event of an emergency.

Date *

YYYY

Name *

Prefix

First *

Last *

Suffix

Parent's Name (if a minor)

Prefix

First

Last

Suffix

Phone Number

###

####

Cell Phone Number

###

####

Address

Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country

Emergency Contact Information

A description of the section goes here.

Emergency Contact #1 *

Prefix

First *

Last *

Suffix

Relationship *

Phone Number *

###

####

Emergency Contact #2

Prefix

First

Last

Suffix

Relationship

Phone Number

###

####

Medical Information

A description of the section goes here.

Physician's Name *

Physician's Phone Number

###

####

Preferred Hospital

Drug, Food or Other Allergies

List of Current Medications

Check all that apply:

Diabetes

Heart (Pacemaker, Stents)

High Blood Pressure

Asthma

Seizures

Other (explain below)

Details/More Information

I have an Advanced Directive

Resusitate

Do Not Resusitate

On file at (home/hospital/nursing home):

Thank you for completing this form. This confidential information will be kept on file in the Church Office and will only be made available to FBC members who are trained medical personnel.

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