Red Badge E-pack: Vehicle, Medical Information Form

Page #5 - VEHICLE Medical Information Form

PLEASE USE A PENCIL ON THIS FORM AND UPDATE IT REGULARLY

Print additional forms for each driver at kpho.com

_______________________________________________________ First Name Last Name Address (Optional)_______________________________________________________ Primary Phone__________________________________________________________ Year of Birth_______

Male__ Female__

Emergency Contact Information: Name:___________________________________________________________________ Home Phone:_____________________________________ Work Phone:______________________________________ Cell Phone:_______________________________________ Primary Care Physician

Attach Recent Photo Here

Date this information was last updated: ____/____/_______

____/____/_______

____/____/_______

____/____/_______

Medical Status

Handicaps

†Heart Problem

†

Sight

†Lung Problem

†

Speech

†Diabetes

†

Hearing

†Asthma

†

Paralysis

†Stroke

†

Right Arm

†Pacemaker

†

Left Arm

†High Blood Pressue

†

Name: _______________________________________________________________

Right Leg

†Cancer/Type_________________

†

Left Leg

Phone: _______________________________________________________________

Do You have a DNR Form? (Do Not Resuscitate)

___Yes ___No

Medical History

Allergies

________________________________

________________________________

Are you responsible for transportation for anyone? __Yes __No __school __daycare __adultcare __work __other

________________________________

________________________________

If yes, please provide:

________________________________

________________________________

Name of person____________________________________________

Medications/Milligrams & Referring Physician

Facility Name/Phone: _______________________________________

________________________________________________________________

Are you a caregiver? __Yes __ No If yes, who needs to know you will not be coming to take care of them?

________________________________________________________________

Name ____________________________________________________ Phone____________________________________________________

________________________________________________________________ ________________________________________________________________

Do you have a pet at home? __Yes __No

For more information or to print additional Medical Information Sheets, please visit www.kpho.com. Click on the CBS 5 Red Badge E-Pack tab and select the form you need.

Health Insurance Company

**PLEASE NOTE THAT THE DNR FORM MUST BE PRINTED ON BRIGHT ORANGE PAPER and is available at any office supply or copy center.

Hospital Preference______________________________________________

Name___________________________________________________________

Page 5

(This does not guarantee transport to preferred hospital)

(Page #5) This piece goes in the glove compartment of your vehicle. Please make sure that the E-Pack Logo faces up and the postcard for first responders is inside.

This program was made possible by:

The Honorable Janet Napolitano GOVERNOR Richard Fimbres Director

The CBS 5 RED BADGE E-PACK

Additional information and comments_____________________

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ _______________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________

This community education program was designed to save lives and is a project developed in conjunction with the Arizona Governor’s Office of Highway Safety. The vehicle portion of this program consists of a Recent Photo, Medical Information Form, two E-PACK Decal stickers and a post card for first responders to fill out and send in to the state. You should place the decal stickers in your vehicle. (One in the front ri g h t , p a s s e n g e r s i d e a n d o n e i n t h e r e a r l e f t , d r i v e r s i d e w i n d o w ) T h i s i n f o r m a t i o n f o r m s h o u l d be f i l l e d o u t i n P E N C I L a n d s h o u l d b e upd ated as needed. Please place the completed form in the g l o v e c om pa r t m en t of y ou r v e h i c l e .

For more information, please call : Tucson: (520)790-5124 310 S. Williams Boulevard, Suite 315 Tucson, AZ 85711 Phoenix: (602) 255-3216 3030 N. Central Avenue, Suite 1550 P h oe n i x , A Z 8 5 0 1 2

In the event of an emergency, first responders can identify the vehicle as that of a CBS 5 Red Badge E-Pack prog ram participant and will k n o w t o l o o k i n s i d e t h e g l o v e c o m p a r t m e n t f o r t h i s p e r ti n e n t , l i f e saving information. Red Badge

**If you sell your car; please remove the information and the stickers from your vehicle.

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