Card

CARD

In case of a confirmed Public Health Emergency, you will need the following health information with you to pick up medication for each person in your family.

Fill out a medical card for each family member and keep it with you at all times. You will need your family’s card to pick up medication at your Medication Distribution Site.

Name: _____________________________ Sex: _______

Address: _______________________________________

_______________________________________________

Phone #: ___________________________

Date of Birth: ________________ Weight: _____________

Allergies: _______________________________________

_______________________________________________

Medical Conditions: _______________________________

_______________________________________________

Pregnant or Breastfeeding ___________________________

Medications: ____________________________________

______________________________________________

Doctor: _________________ Doctor Phone: __________

Date of last Tetanus shot: __________________________