Free 46213.pdf - Indiana

INFORMATION REQUIRED IN AN EMERGENCY
State Form 46213 (10-93)

CLIENT INFORMATION Name of client

Address (number and street, city, state, ZIP code)

T elephone number

Date of birth

Social Security number

PERSON TO BE NOTIFIED IN CASE OF EMERGENCY DURING THE DAY Name Relationship

Address (number and street, city, state, ZIP code)

T elephone number

FAMILY DOCTOR Name

Address (number and street, city, state, ZIP code)

T elephone number

MEDICAL INSURANCE Policy number

Disabilities or health problems:

Medication:

Allergies (Medications and other): Do you wear: Contacts Dentures I hereby authorize Blind and Visually Impaired Services to obtain emergency medical and / or hospital services. Signature of client Date signed