EMERGENCY MEDICAL INFORMATION AND CONSENT FOR TREATMENT
Date: 

Name:


Home Address:


Work address:


Medical Problems:
Allergies: 
Medicines I Take: 
Blood Type: 
Religious Affiliation: 
vision:  contacts/glasses/no eye-wear

Primary Care Physician:

Dentist:

In case of emergency, notify:

Treatment Waiver: If I am unable to communicate, I, the undersigned, do
hereby authorize any examination or treatment by any physicran, dentist or
medical aide licensed by the state
(you can list states by saying of ... if you want to restrict the region)
for myself.  Permission is given to
encourage the use of their best judgment as to the requirements of any
diagnosis of medical or dental or surgical treatment.  This consent shall
remain in effect until rescinded by me.

Signature:


You can download a copy of this form, fill it out and carry it with you. Modify as needed. The form is in html, so after inserting your information, just point your browser at it and print from your browser. The original form was provided by the Potomac Pedalers Touring Club after one of the members fell and was knocked unconscious. They did not carry identification, but fortunately their cell phone was programmed to contact a relative. You can help others to help you by filling out this form. This page is at: http://www.fred.net/tds/emergencyform.html