Please post one of these completed sheets on the refrigerator for each person living in your

Please post one of these completed sheets on the refrigerator for each person living in your

home. Please remember to remove sheets when a person moves out of the house.

Elizabeth Fire Dept. personnel know to look for these sheets on the refrigerator in the case

of an emergency at your home. Please update this form as needed to keep it current.

MY PERSONAL MEDICAL INFORMATION

Todays Date:_____________________

Name:_____________________________________ Date of Birth:_____________________ Male___Female_____

Male_____Female______

Please Contact:_________________________________________ At Phone #: ___________________________________________________

Secondary Contact:______________________________________ At Phone #: ___________________________________________________

My Primary Care Doctor:__________________________________ At Phone #: ___________________________________________________

My Preferred Hospital:____________________________________

Medical Concern:____________________________Prescription:______________________Dose______X____Daily

I wish to be resuscitated:__________________ I do not wish to be resuscitated:_______________________________

My DNR or CPR directive is located:___________________________________________________________________

Please do these things for me before you go:

Lock the doors:______Other:______________________________________________________________________________________________

My pets names are:____________________________Please put them outside:____In this room:___________________