Paramedic Alert Enrollment Form

Paramedic Alert - Enrollment Form by Internet

Residence Address:	Apt:
Telephone:
City or Township:
Person completing form:	Phone:
Special directions to home:

Name:
Major medical problems:
Current medications:
Drug allergies:
Physician:
Physician phone:
Birthdate:
Perferred hospital:
Advanced Directives:	Yes No
If so, where are they?
Other important information:
E-Mail Address:

Submit a new form for each person you wish to register. You will receive an acknowledgement within 72 hours of submitting this form. It will be sent to your e-mail address, or to the address above.

Note: Information is maintained on file for 2 years. You must resubmit this information or it will be purged.

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