Medical Alert Information Form

2. Last Name*

3. First Name*

5. Address*

7. City*

8. Zip Code*

10. Phone Number*

14. Medical Condition

    1. Alzheimer’s/Memory Impaired
    2. Asthma (Acute)
    3. Autism
    4. Bedridden
    5. Blind/Difficulty Seeing
    6. Companion Animal
    7. Deaf/Hard of Hearing
    8. Deaf – Required use of a TDD (Telecommunications for the Deaf)
    9. Diabetic (Acute)

    1. Heart Condition
    2. High Blood Pressure
    3. Oxygen Supply use
    4. Other (please explain):
    5. Physically Handicapped, uses cane, walker, wheelchair, etc. (please explain):
    6. Psychiatric/Emotional Problems
    7. Speaking Difficulty
    8. Seizures

16. Allergies

    1. Allergic to medications
    2. Food Allergies
    3. Other (please explain)

17. List all specific information regarding known allergies that cause a reaction

19. Electronic Signature Agreement*

    By checking the "I agree" box below, I hereby authorize law enforcement, fire/rescue, and EMS/ambulance to enter my residence, if it is believed that I am in need of assistance and incapacitated. I also acknowledge that it is my responsibility to notify Clinton County Central Dispatch of any modifications to stated information on this form.

    1. I agree.
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21. 1. Receive an email copy of this form.
22. Email address

    This field is not part of the form submission.

23. Submit Submit and Print

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