Vial of Life Project

A Division of the Bridge Building Foundation

a 501 (c) 3 Public Charity

All information on this form is optional, but being thorough and providing as complete information as you can helps emergency crews help you.

EMERGENCY MEDICAL INFORMATION – FOR RESCUE SQUAD
Sponsored by American Senior Safety Agency – Phone Toll Free (888) 473-2800
VIAL OF LIFE

Basic Information

First Name

M.I.

Last Name

Date of Birth

Only give the info you feel comfortable providing. You also can handwrite your Social Security # or any other info on this form once printed.

Social Security

Email

Street

City

State


Zip Code

Phone

Male

Female

Height

Weight

Hair Color

Eye Color

Blood Type

Religion

If Pacemaker – Model #

If Defibrillator – Model #

Hearing Aid

L
R

Deaf

L
R

Vision

Glasses

Contact Lenses

Blind

L
R

Artificial Eye

L
R

Native Language

Medical History
Providing a current picture with your Vial of Life information can also help emergency crews identify and help you quickly.

Identifying Marks :


Conditions you have been treated for in the past:


Current Medical Information

Doctors Name and Telephone Number:


Unsure about your medical information? Bring this Vial of Life form to your next doctor’s visit. Your doctor should be glad to help fill this out.

Currently Being Treated For :


Unsure about your complete list of medications? Bring this Vial of Life form to your next doctor’s visit. Your doctor should be glad to help fill this out.

Current Medications:


Allergies To Medications:


Last Hospitalization

Hospital

Location

Year

Patient #

Living Will

Refer To

Organ Donor

Refer To

Medical Coverage

Blue Cross #

Blue Shield #

Medicare #

Medicaid #

Other

Policy #

Emergency Contact
Provide your Contact with other phone numbers to call for family & friends. They can then notify everyone on your list if you have an emergency.

In Case Of Emergency – Notify

Relationship

Phone

Address

Apt

City

State


Zip