Emergency Medical Information Card (Wallet Size)

...........................................................
EMERGENCY CONTACT

Name: _____________________
Dylan Schmidt ___________________
Name: Mary Smith

Phone: _____________________
513-780-5147 DOB: _________
11-13-1972 Blood Type: ______
A Negative

Address: ____________________
PHYSICIAN CONTACT (PRIMARY)
123 Winding River Ln.
Name: _____________________
Dr. Mark Stelly
City: _______
Somewhere
State: AK___ Zip: ______
12345
Phone: _____________________
347-218-9371
PHYSICIAN CONTACT (SPECIALTY)
Contacts Dentures: Metal in Body: ✔
Name: _____________________
Dr. Ryan Williams
:
Diabetic: Epi Pen: ✔
Phone: _____________________
521-648-9274

____________________
Specialty: Rheumatologist
DNR: Living Will: Organ Donor:
...................................................................................

____________________

____________________

____________________

____________________

____________________
________________

________________

________________

________________
Depression 1x/day 25mg Zoloft
592-437-1233 Ryan Williams Depression
Rheumatoid Arthritis 1x/day 5mg Xeljanz
713-620-4783 Alex Gonzalez Rheumatoid Arthritis
Seasonal Allergies 1x/day 10 mg Singulair
Phone # Doctor Diagnosis
Reason How Often Dosa Rx Name
MEDICAL CONDITIONS
MEDICATIONS
__________

__________

__________

___________________
273-492-2815
Phone #:

Non-Steroid Anti-Inflammatory Drugs Air Passageway Closes Up Address: ___________________

345 Crossing Blvd. Kalamazoo, ID 13573
REACTION (Food, Drug, Latex)
ALLERGIES
___________________
Pharmacy: CVS

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