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Reviewed by the Faculty of Harvard Medical School


Last Updated:
The Aetna InteliHealth Record Of Emergency Contact Information makes it easy to keep important information within reach for you and your child’s caregivers. Simply fill in each of the boxes below, and we’ll produce a personal record that you can print (select "Print" from the "File" menu) and cut out. Carry one copy with you, keep a second at your home and give one to your child’s caregivers. We also suggest downloading the form to the hard drive on your computer (select "Save As" from File menu), so you can update this information as needed.
Emergency Phone Numbers:
Police Department:
 Ambulance:
Fire Department:
 Child's Doctor:
Poison Control Center:
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Parents' Phone Numbers:
Parent's Name:
 Parent's Name:
Home:
 Home:
Office:
 Office:
Cell:
 Cell:
Pager:
 Pager:
Child's Doctor:
Name:
 Address:
Day Phone:
Emergency Phone:
Emergency Contacts:
Name:
 Name:
Day Phone:
 Day Phone:
Evening Phone:
 Evening Phone:
Relationship:
 Relationship:
Address:
 Address:
Medical Information:
Child's Name:
 Child's Name:
Date Of Birth:
 Date Of Birth:
Medical Problems:
 Medical Problems:
Medicines:
 Medicines:
Allergies:
 Allergies:
Child's Name:
 NOTES:
Date Of Birth:
Medical Problems:
Medicines:
Allergies:
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Last updated June 28, 2005



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