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southern new mexico surgery center
 
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    Health Library Explorer
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    Children's Health

    Emergency Information Form

    In an emergency, it's easy to forget even the most well-known information. That is why it's vital for you to fill out the information in this form for each person in your home. Then give copies to each person in your household. And post all copies in easy-to-find places in your home, car, or workplace. Update the information often.

    Also make copies for nonresident relatives, babysitters, caretakers, neighbors, teachers—anyone who has contact with you, or who is sometimes responsible for your children. And make copies for any adults in your home who have a disability or who are older.

    If you own a smartphone, put two different contacts in your phone under ICE for "in case of emergency." Then the emergency room staff can call your contacts if you're not able to communicate. Examples could be ICE-Mom or ICE-Husband to identify your contact. Newer smartphones have apps that you can download to make this information easier to access. But don't rely on your smartphone. It may be out of power, overlooked, or not with you at the time. It's still vital to have additional copies of this form.

    Emergency phone numbers

    911

    Or use the number for your local emergency transport system (if the 911 system isn't available in your area):

    _____________________________________________________________

    Post the poison control center phone number by every phone in your home and add the phone number to all cell phones. The national, toll-free poison control center locator number is: 800-222-1222.

    From here, you will be automatically redirected to the nearest Poison Center in your area.

    Poison control                                                                                                    

    Healthcare provider's name and telephone

    Hospital emergency room

    Police

    Fire

    Other

    This information is for

    Person's full name                                                                        

     

     

    Date of birth

     

     

    Height

    at last physical on:                                                                      

    Weight

    at last physical on:

    Home address

    Directions to home

    Home phone/cellphone

    Allergies

    Health conditions

    Current medicines

    Emergency contacts

    Contact person #1                                                                           

     

     

     

     

    Name

    Relationship

    Work or home address

    Phone:

    Home                                      

    Work                                             

    Contact person #2

    Name

    Relationship

    Work or home address

    Telephone

    Home

    Work

    Contact person #3

    Name

    Relationship

    Work or home address

    Phone

    Home

    Work

    Additional instructions

    Online Medical Reviewer: Eric Perez MD
    Online Medical Reviewer: Raymond Turley Jr PA-C
    Online Medical Reviewer: Tara Novick BSN MSN
    Date Last Reviewed: 3/1/2023
    © 2000-2024 The StayWell Company, LLC. All rights reserved. This information is not intended as a substitute for professional medical care. Always follow your healthcare professional's instructions.
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    Southern New Mexico
    Surgery Center

    2301 Indian Wells Rd. Suite B
    Alamogordo, NM 88310
    www.snmsc.org

    Phone: 575.437.0890
    Fax: 575.437.0905
    Email: info@snmsc.org

    Disclaimer