Emergency Medical Information Form

This form is provided by and maintained by National Set & Event Medics to help our medical staff treat you in the event you are incapacitated. This form is HIPPA compliant and remains confidential. Your employer does not have access to the information you provide on this form.

Download the printable copy here: http://emi.nationalsetmedics.com

Production:

First Name

Last Name

Mobile Number

Email Address

Emergency Contact Person

First and Last Name | Preferably someone not with you

Emergency Contact Phone Number

Relationship to you

Do you have any Allergies?

If none type none

What Medications are you taking?

If none, type none

Past Medical History

If none, type none

What is your doctors name?

If none, type none

Doctors Phone Number

If none, type none

Any Additional Notes?