VIAL OF LIFE

Complete form and insert it into the plastic “Vial of Life”. Place vial on the top right hand shelf of your refrigerator. Location stickers are provided and may be applied to the outside of your refrigerator door. Your participation will provide emergency personnel with immediate access to your vital medical information.

Name:_________________________________________ Date of Birth:_____________________

Address/Zip Code:_________________________________________________________________

Emergency Contact:________________________________________________________________

(Name) (Relationship)

Address/Zip Code:________________________________ Telephone:_______________________

Doctor’s Name:___________________________________ Doctor’s Phone:___________________

Hospital Preferred:_________________________________________________________________

IMPORTANT MEDICAL INFORMATION

Check if you are being treated for, or have a history of:

[ ] Heart Disease [ ] High Blood Pressure [ ] Visual Impairment

[ ] Diabetes [ ] Low Blood Pressure [ ] Speech Impairment

[ ] Epilepsy [ ] Hearing Impairment

List any other medical conditions you have._____________________________________________ _______________________________________________________________________________

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What medications are you presently taking? ____________________________________________

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Do you wear contact lenses? [ ] Yes [ ] No

Do you have a “Living Will”? [ ] Yes [ ] No

Do you have a pacemaker? [ ] Yes [ ] No

Any other information deemed important: _______________________________________________

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