Free Medical Records Form

Print out this form and complete by hand. Keep a copy on your refrigerator (Enclose in zip-lock bag)
This form provided as a courtesy of MedIDs.com Form Printed:

Note: There is an economical program available that would enable Physicians, Hospital ER, etc. to access your Medical Information by telephone or On Line 24/7
View Program Here - MedIDs.com

Name:
Address:
City and State:
Date of Birth:	Month:	Day:	Year:
Medical Directives: (Circle)	Organ Donor: Yes No	DNR: Yes No	Other:
Physician:	Phone:
Physician:	Phone:
Other Medical Data:	Blood Type:	Weight:	Height:
Miscellaneous Information:
Primary Medical Condition :
Other Medical Conditions :
Other Medical Conditions :
Other Medical Conditions :
Drug Allergies :
Drug Allergies :
Food/Insect Allergies :
Implants, etc. :
Hospital Name/Phone No. :
Pharmacy Name/Phone No. :
Previous Surgeries: :
Previous Surgeries: :
Previous Surgeries: :
Lab Test: :	Results
Lab Test: :	Results
Other: :

This form provided as a courtesy of MedIDs.com - Provides affordable Medical ID Jewelry and Medication pill carriers

IN CASE OF EMERGENCY CONTACTS Next Page

Enter in form below people to contact in the event of an emergency!

Name	Relationship	Phone Number	Work/Cell/Home

Enter the medications that you are taking at the present time.

Drug Name	Dosage	Frequency	Pharmacy Rx No.

Terms of Use: In the printing and completion of this form, MedIDs.com makes no guarantee regarding the completeness or accuracy of the information entered above. Information on the card is generated based on the information supplied by the user completing this emergency medical form. Any risk arising from the use of the information above remains with the user.

Consent to Treat - Optional

Physicians and hospitals are authorized to photocopy this medical record. In case of emergency, I,_____________________________________________ , authorize anyone to administer first aid and Any licensed physician to render medical treatment and perform necessary surgery. When time permits, the need for major surgery must be agreeded upon by two qualified physicians. The surgeon may select the anesthetist of his/her choice.

I hereby authorize any physician or hospital to furnish full information concerning my medical condition and medical history to anyone rendering medical treatment to me or my child.

Signature _______________________________________________________________________________

In case of emergency, I,_____________________________________________ , authorize the following person/s to discuss my medical condition with physicians, hospitals and or other healthcare providers.

________________________________________________________________ Relationship__________

This form was completed by:________________________________________________

Date completed: _____________________________________________

This form provided as a courtesy of MedIDs.com