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In an emergency, it is easy to "forget" even the most well-known information. That is why it is crucial for you to complete the information in this form for each member of your household. Then, distribute copies to each member of your household. Also, post all copies by each telephone and in easy to find places in your home, automobile, or place of business. Be sure to update the information frequently.
Also, make copies for non-resident relatives, babysitters, caretakers, neighbors, teachers - anyone who has contact with you or who is periodically responsible for your children (or any disabled or elderly persons in your home).
Emergency Telephone Numbers:
9 1 1 (nine, one, one)
Emergency Transport System
(if 9-1-1 system is not available in your area)
Post the poison center telephone number by every telephone in your home. The national, toll-free poison control center locator number is: 1-800-222-1222. From here, you will be automatically redirected to the nearest Poison Center in your area.
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Poison control
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Physician's name/telephone
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Hospital emergency room
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Police
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Fire
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Other
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This information is about:
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Person's Full Name
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Date of birth
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Height
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at last physical in:
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Weight
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at last physical in:
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Home Address
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Directions to Home
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Home Telephone
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Allergies
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Medical Conditions
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Current Medications
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Emergency Contacts:
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Contact Person #1
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Name
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Relationship
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Work or Home Address
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Telephone:
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home
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work
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Contact Person #2
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Name
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Relationship
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Work or Home Address
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Telephone:
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home
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work
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Contact Person #3
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Name
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Relationship
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Work or Home Address
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Telephone:
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home
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work
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Additional Instructions:
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The information on this Web page is provided for educational purposes. You understand and agree that this information is not intended to be, and should not be used as, a substitute for medical treatment by a health care professional. You agree that Lucile Salter Packard Children’s Hospital is not making a diagnosis of your condition or a recommendation about the course of treatment for your particular circumstances through the use of this Web page. You agree to be solely responsible for your use of this Web page and the information contained on this page. Lucile Salter Packard Children’s Hospital, its officers, directors, employees, agents, and information providers shall not be liable for any damages you may suffer or cause through your use of this page even if advised of the possibility of such damages.
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Lucile Packard Children's Hospital is located in Palo Alto, adjacent to Stanford University Hospital, approximately 20 miles north of San Jose, CA and 40 miles south of San Francisco.
Lucile Packard Children's Hospital
725 Welch Road
Palo Alto, California 94304
(650) 497-8000
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