| See text below for instructions and warning.
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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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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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