Emergency Information

Complete this FORM and seal it in an envelope, then place it in your RV, taped to the refrigerator,
inside closet or, if a tent camper, to the top of your ice chest so it can be found and passed on to
medical personnel in an emergency.
Name: ____________________________________________ Age: _
Address: ____________________________________________________________

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Phone Number: _____________ Email: _________________
Date of Birth: _______________ Blood Type: _____________
□ Diabetes □ High Blood Pressure □ Heart Disease □ COPD
□ Asthma □ Contact Lenses/glasses □ Cancer
□ Other: ________________________________________________________
□ Metal in body (What/Where)? ______________________________________
Medications & Dosages: _____________________________________________

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Allergies: _________________________________________________________
Dietary Restrictions: ________________________________________________
Other information to be aware of: ______________________________________

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Medical Insurance Carrier: ___________________________________________
Primary Physician Contact Information: _________________________________

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Who to contact in case of emergency:
1) ________________________________________________Ph._______________________
2) _______________________________________Ph._______________________