EMS Patient Information Form

When you call 911 for an EMS response, the scene can be scary and hectic. EMS will be trying to assess your condition, perform any immediately life-saving interventions, all the while trying to learn what medications you take, what allergies you have, and what your pre-existing health conditions are. If you are having a hard time breathing, will you be able to tell them all that information? If you have stroke symptoms, will you be able to talk at all?  If you have a diabetic emergency, will you even be conscious? Do you live alone or does the person you live with know all of your information or where to find it? Will they be calm enough to do so? You can do something now that will make the difference. By completing the EMS Patient Information Form (PDF) you can Help EMS Help You!

The EMS Patient Information Form (PDF) can be filled out in advance and placed on your refrigerator for EMS to utilize to help you more quickly.  It is designed to fold over with your name on the front, to protect your health information that is on the inside.  By having one form used by citizens in Henry County, any ambulance from any agency that responds to your call for assistance will know exactly where to look for your medical information.  EMS will need to take this form with you to the hospital, where it will also assist Emergency Room personnel in providing you with timely care.  It is wise to make two copies, one to travel with EMS and one to leave at home. 

Henry County Department of Public Safety asks that you consider using the EMS Patient Information Form (PDF) so that you can Help EMS Help You!

Access the EMS Patient Form (PDF) in a fillable document or to print off and complete with a pen. Be sure to print out two forms for each person in the household who has pre-existing health conditions or severe allergies. Other ways to obtain the EMS Patient Information Form (PDF) include calling, emailing, or Facebook messaging your local Rescue Squad or Henry County Department of Public Safety to set up a time to pick up a form, receive it by mail, text, Facebook message, or email.

The time saved and the information provided on the EMS Patient Information Form (PDF) can make a tremendous difference in how quickly EMS can safely assess and treat you. For questions or assistance with the form, please call HCDPS Deputy Director, Suzie Helbert at 276-634-4662 or email Suzie Helbert.

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