Madeline SchwartzCaregiver Reference Sheet
February 1st 2007 15:16
Suggestions:
* Have this information about the person you care for handy when you call for services.
* Place your sheet in the refrigerator.
* Use it as an introduction guide if you have home care, nurse, therapist.
* Always keep this information in one place.
Address:
Birth Date:
Social Security Number:
Medicare Number: Medicaid Number:
Insurance Name: ID number:
Insurance Agent: Phone:
Emergency/Ambulance Number:
Doctor’s Name: Phone:
Pharmacy: Phone:
Blood Type: Medications (Name and Dosage):
Food Allergies:
Drug Allergies:
Style & Serial Number of Medical Devices:
DNR (Do Not Resuscitate) Form: __ No, I Do Not Have __ Yes, I Have
Form Location:
Health Care Proxy On File At:
Emergency Contact (s):
Name
Home Phone: Work Phone:
Contact:
Home Phone: Work Phone:
Special Notes:
* Have this information about the person you care for handy when you call for services.
* Place your sheet in the refrigerator.
* Use it as an introduction guide if you have home care, nurse, therapist.
* Always keep this information in one place.
Reference Sheet
Legal Name:Address:
Birth Date:
Social Security Number:
Medicare Number: Medicaid Number:
Insurance Name: ID number:
Insurance Agent: Phone:
Doctor’s Name: Phone:
Pharmacy: Phone:
Blood Type: Medications (Name and Dosage):
Food Allergies:
Drug Allergies:
Style & Serial Number of Medical Devices:
DNR (Do Not Resuscitate) Form: __ No, I Do Not Have __ Yes, I Have
Form Location:
Health Care Proxy On File At:
Emergency Contact (s):
Name
Home Phone: Work Phone:
Contact:
Home Phone: Work Phone:
Special Notes:
| 55 |
| Vote |
subscribe to this blog
