Confidential Medical Emergency Information

*Insurance Company
*Insured's Name
Group Number:
Primary Physician name / address / phone #:
*Emergency Contact Name / relationship / primary and work phone:
Medications and dosage that you are currently taking:
Please list all drugs / medicines which you are allergic::
Are you in good health? If not, please briefly describe any condition (physical or emotional) your leader should know about.:
Please list any unusual medical conditions that you feel it would be helpful for a physician to know in the event you were to re:
*Are you pregnant?:
If pregnant, how far along are you?:
EMERGENCY AUTHORIZATIONTO WHOM IT MAY CONCERN: I, the undersigned, hereby give any licensed, practicing physician or hospital full authority to provide emergency medical treatment for me in the event such treatment is needed or necessary and I am not able to make such a decision. I also hereby give my permission for a licensed practicing physician to administer whatever medical treatment he/she may deem necessary for me in the event of any medical emergency affecting me.
*signature:
Date: