CHOC Children's
COMMON INJURY/POISON

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 about:

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 Common Childhood Injuries & Poisonings

GR_ATP

It is important to remember the health information found on this website is for reference only not intended to replace the advice and guidance of your healthcare provider. Always seek the advice of your physician with any questions you may have regarding a medical condition. If you think you may have a medical emergency, call your physician or 911 immediately.

© Children's Hospital of Orange County