Paramedic Alert - Enrollment Form by Internet

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Residence Address:   Apt: 
Telephone:
City or Township:
Person completing form:   Phone:
Special directions to home:
Name:
Major medical problems:
Current medications:
Drug allergies:
Physician:
Physician phone:
Birth date:
Preferred hospital:
Advanced Directives: Yes   No
If so, where are they?
Other important information:
E-Mail Address:

Submit a new form for each person you wish to register.  You will receive an acknowledgement within 72 hours of submitting this form.  It will be sent to your e-mail address, or to the address above.

Note:  Information is maintained on file for 2 years.  You must resubmit this information or it will be purged.

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