VIAL OF LIFE
Instructions:
· Fill
out this form and check the information with your doctor.
· Put the
form in the plastic vial [empty prescription bottle]
· Place it on
the top shelf of your refrigerator door.
· Put a Vial of Life decal
on the door or window of the main entrance of your home. ·
For vehicle use,
· Put the vial in your glovebox and affix a
"Vial of Life" decal to a window.
************************************************************************
Warning
Consider the risk of identity theft when leaving
personal information in an
unattended vehicle in a public place against the
benefits of having it available to emergency medical personnel. ************************************************************************ Be
sure to keep your medical information current. Name___________________________________Year
of birth______________
Address__________________________________Marital status____________
City & state, Zip____________________________SSN__[Identity Theft Issue]____ Emergency
Contact:
Name____________________________________Phone__________________
Address_________________________________________________________ Insurance
Co./Health Care Provider__________________________________
Primary Policy
# ___________________________________________________
Secondary Insurance
Co._____________________________________________
Secondary Policy #_________________________________________________
Doctor's name_______________________________Phone #_______________ Medical
Conditions/history:
________________________________________________________________
________________________________________________________________ Surgeries:
________________________________________________________________
________________________________________________________________ Allergies:________________________________________________________
________________________________________________________________ Current
medications______________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________ Over
the counter medications you take_______________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________ Immunizations/dates______________________________________________
________________________________________________________________
Date completed____________________________
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