Community Health Network

Ranked among the nation's most integrated healthcare systems, Community Health Network is Central Indiana's leader in providing convenient access to exceptional healthcare services, where and when patients need them—in hospitals, health pavilions, workplaces, schools and homes.

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Emergency Information Form

In an emergency, it is easy to "forget" even the most well-known information. That is why it is crucial for you to complete the information in this form for each member of your household. Then, distribute copies to each member of your household. Also, post all copies by each telephone and in easy to find places in your home, automobile, or place of business. Be sure to update the information frequently.

Also, make copies for non-resident relatives, babysitters, caretakers, neighbors, teachers - anyone who has contact with you or who is periodically responsible for your children (or any disabled or elderly persons in your home).

Emergency Telephone Numbers:

9 1 1 (nine, one, one)

Emergency Transport System
(if 9-1-1 system is not available in your area)

 

Post the poison center telephone number by every telephone in your home. The national, toll-free poison control center locator number is: 1-800-222-1222. From here, you will be automatically redirected to the nearest Poison Center in your area.

Poison control
Physician's name/telephone
Hospital emergency room
Police
Fire
Other

This information is

Person's Full Name
Date of birth
Height at last physical in:
Weight at last physical in:
 
Home Address
Directions to Home
Home Telephone
 
Allergies
 
 
 
 
 
Medical Conditions
 
 
 
 
 
Current Medications
 
 
 
 
 

Emergency Contacts:

Contact Person #1
Name
Relationship
Work or Home Address
Telephone: home work
 
Contact Person #2
Name
Relationship
Work or Home Address
Telephone: home work
 
Contact Person #3
Name
Relationship
Work or Home Address
Telephone: home work
 

Additional Instructions:

Click here to view the
Online Resources of Non-Traumatic Emergencies

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