Download Senior Citizen Emergency Medical ID Kit for Free

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Senior Citizen
Emergency Medical ID Kit
Dear Senior Citizen,
The Momence Police Department is, as always, interested in your safety first.
If a medical emergency occurs in your home, seconds may be precious! This Emergency Medical ID Kit is
intended to provide Emergency Responders with the information they need to quickly treat a patient at the scene
and transport the patient to the hospital for treatment. There should be one completed ID Kit for every potential
patient in the home. Once fully completed, attach the ID Kit to your refrigerator where emergency responders
can easily locate it. Store all your medications in one location and note that location on this form. Keep this
form up to date by printing needed copies from http://police.cityofmomence.com
ss #
Any Allergies to Medications, Foods, or stings?
Month and Year?
Any Recent or Past Surgeries?
Medical Conditions (Post and Present?)
Policy Number
Insurance Company Name
1.)
2.)
2.) Affix to your refrigerator in plain view.
1.) Fill out form completely and keep updated.
Last Name
First
Middle
Address
City
State
Zip Code
Phone
Gender
M/F
Birth Date Blood Type
Age
Doctor
Phone #
Doctor Phone #
Emergency Contact
Phone #
Phone #
Emergency Contact
Health Records At:
Living Will?
DNR?
Yes / NoYes / No
Current Medication
Frequency
Dosage
Where can medications be found?
Senior Citizen Emergency Medical ID Kit
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