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2. Attention Paramedics
   Important Medical Information
4. Name
6. Date of Birth
7. Sex
9. Address
11. City
12. State
13. Zip Code
15. Current Illness / Condition
17. Current Prescription and Non-Prescription Medication
19. Pacemaker

    1. Yes

    1. No
21. Allergies to Medications
23. Preferred Hospital
25. Additional Doctor
    Include phone number and specialty
27. Additional Doctor
    Include phone number and specialty
29. Additional Doctor
    Include phone number and specialty
31. Hospitals which have your records
33. Major surgeries you have had (month and year)
37. In Case of Emergency
39. Name
40. Relationship
42. Phone Number
43. Alternate Phone Number
45. Name
46. Relationship
48. Phone Number
49. Alternate Phone Number
51. Living Will

    1. Yes

    1. No
52. Durable Power of Attorney for Health Care

    1. Yes

    1. No
54. State of Ohio Comfort Care Orders

    1. Yes

    1. No
55. Do Not Resuscitate (DNR) Orders

    1. Yes

    1. No
Leave This Blank:


57. 1. Receive an email copy of this form.
58. Email address

    This field is not part of the form submission.

59. Submit

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