For Caregivers
Emergency Card
Last Updated:
An Emergency Card is always helpful to have on hand. In a crisis it may be difficult to remember important information. Also, a person's care can be compromised or delayed if emergency or hospital staff must make decisions without knowing pertinent facts such as medications, existing medical conditions and preferred physicians/facilities. An Emergency card is especially important if the person with brain injury has trouble communicating, has seizures, lives alone or is often in the care of others who may not have his/her medical and insurance information.
To create a durable Emergency Card:
- Print the following form.
- Complete with information requested
- Cut leaving 1/4" border around form
- Fold in half to reduce size
- Laminate
- Keep visible someplace where it is likely to be found (Near bed, phone, kitchen)
Personal Information
Name__________________________ Ph_______________
Address__________________________________________
Emergency contacts
______________________________ Ph_______________
______________________________ Ph_______________
______________________________ Ph_______________
Date of Brain Injury_________________________________
Other info________________________________________
________________________________________________
________________________________________________
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Name Phone
Hospital _______________________
Specialist______________________ _________________
Primary Care ___________________ _________________
Insurance______________________ _________________
Precertification phone #
Member ID#________________ Group# _______________
Current Meds Dosage
____________________________ __________________
____________________________ __________________
____________________________ __________________
For a wallet-size version, download our Emergency Card.