- Mt. Morris Fire Protection District -
- Vial of Life Form -
Name:______________________________________________________________ Phone:_________________________________________
Address:____________________________________________________________ City:_________________ State:_______ Zip:_______________
Birth Date:____________________
Family Doctor:__________________________________ Hospital of Choice:______________________________
Emergency Contact #1 Emergency Contact #2 Emergency Contact #3 / Power of Attorney is applicable
Name:_________________________________________ Name:________________________________________ Name:_______________________________________
Phone:_________________________________________ Phone:_______________________________________ Phone:______________________________________
You can stop at the Firehouse for help on the Following:
Blood Pressure:_________________________________
Pulse Rate:_____________________________________
Respirations:____________________________________
Past Medical History:______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________
Allergies:________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Medications:______________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________
Special Needs:
Oxygen Y / N How Many Liters ____________LPM
DNR Y / N Location:_______________________________________________________________________________
Other Important Information:___________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
Cut apart and place a logo on your baggy and on the freezer door.