This form can be downloaded and filled out on your computer, and then printed. Or printed, then filled out by hand.

PLEASE fill out your emergency medical information and let your closest neighbor know where it is located.

On two occasions in 2023, a neighbor needed to go with a friend to the ER. A medical form would have been very helpful!

Also, a spouse may need this form for the same reason during an ER visit with a husband or wife.

These forms are intended to be placed on the side of the refrigerator which is where emergency responders are trained to look for this type of information. 

Note: This fillable PDF was created using an EMSA
          wallet card as an example.