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.
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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.
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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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