Life Saver Card

Lifesaver Card will make no changes to the information on this form. You assume all liability for the inaccuracies or omissions. With your LifeSaver card you will receive 6 Decals for wallet or purse, one auto windshield sticker and a key tag.

Make sure to include area codes in all phone numbers, and notate all relevant data!

Last Name		First Name
Middle Name
Street Address
Street Address 2
City		State
Zip Code
Home Phone
Mobile Phone
Alternate Phone
Date of Birth
Drivers License #
Gender	Male Female	Height Feet Inches
Weight	Pounds
Ethnicity		Hair Color
Eye Color		Blood Type

Insurance Company
	Policy # Group #
Insurance Company2
	Policy # Group #
Last Hospitalization
	Reason Doctor
Prescription Insurance Company
	Policy # Group #
Responsible party for person named above	Phone
Employer
	Employer ID# Phone Ext.
Street Address
Street Address 2
City	State
Zip Code
Supervisor		Job Title
Hazardous Materials/Conditions
Medicare #
	Hospital Ins. # Policy # Certificate
Personal Physician
City	State
Phone
Surgeon
City	State
Phone
Dentist
City	State
Phone
Emergency Contact #1
	Phone Relationship
Emergency Contact #2
	Phone Relationship
Emergency Contact #3
	Phone Relationship
Special Instructions
Preferences

For the following conditions, provide all relevant details, including locations, dates, causes, etc.

Heavy Drinker Stomach Ulcer Heart Condition Nervous Trouble Fainting Liver Disease Contact Lenses	Attempt Suicide Polio Head Injury Back Trouble Gall Bladder Asthma Boils	Diabetic Epilepsy/Conv. Jaundice Sickelmia Birthing Trouble Ear Problems Stones	Diabetic Coma Hyperventilation Hypertension Hay Fever Arthritis Drug Habit Goiter	Insulin Shock Severe Injury Hepatitis Hemophilia Kidney Disease HIV/ AIDS Thyroid	Depression Back Injury Abdomen Injury Rheumatic Fever Eye Problems Hearing Loss Carpel Tunnel
Do you currently smoke? Have you ever smoked?

Cancer	Remission
Tumor	Benign
Heart Attack
Stroke	How Many
Fractures	How Many
Severe Bleeding
Paralysis
Do you have a living will?
	Contact Phone

List all allergies to medication, as well as other important allergies.
List all medications (with dosages) you take regularly or frequently
List all other current medical, psychiatric treatments.
List all surgeries you have undergone with dates.
Eyeglass/contact lens prescription.
Pharmacy you do business with, include details & contact information.
Any other pertinent information that would be useful in an emergency.

	Emergency Treatment Authorization: I hereby authorize any qualified person to administer first aid and other necessary treatment
	In case of emergency, I hereby authorize any licensed personnel to administer blood transfusion.
	Emergency Surgical Authorization: In case of emergency, I hereby authorize any licensed surgeon and his/her choice of anesthetist to perform surgery if necessary. The need for surgery must be agreed upon by two (2) doctors qualified to make such judgment.
Exceptions

Physicians and hospitals are authorized to access and copy the Life Saver Card (cd-rom) medical record card. In case of emergency, I authorize anyone to administer first aid, blood transfusion, life support. Any licensed physician to render medical treatment and perform necessary surgery. When time permits, two qualified physicians must agree upon the need for major surgery. The surgeon may select the anesthetist of his/her choice. I hereby authorize any physician or hospital to furnish full information concerning my medical condition and medical history to anyone rendering medical treatment.

Authorized by:	Parent Guardian Self
	In order to process this form, you must agree to the following 3 statements!
	I certify that the information contained herein is true and correct to the best of my knowledge & belief.
	I will not hold any doctor, EMT or Hospital or Life Saver Card liable for any misinformation or lack of information on this form.
	By clicking the submit button, I am submitting this with my digital signature and certify that this is filled out for myself, my dependant, or my patient.