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Common Childhood Injuries and Poisonings

Emergency Information Form

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.


Poison control

Physician's name/telephone

Hospital emergency room

Police

Fire

Other

This information is about:

Person's Full Name

Date of birth

Height

at last physical in:

Weight

at last physical in:

 

Home Address

Directions to Home

Home Telephone

 

Allergies

 

 

 

 

 

Medical Conditions

 

 

 

 

 

Current Medications

 
 
 
 

Emergency Contacts:

Contact Person #1

Name

Relationship

Work or Home Address

Telephone:

home 

work 

 

Contact Person #2

Name

Relationship

Work or Home Address

Telephone:

home 

work 

 

Contact Person #3

Name

Relationship

Work or Home Address

Telephone:

home 

work 

 

Additional Instructions:

 





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.


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


Copyright 2008 Lucile Packard Children's Hospital. All rights reserved.
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