Emergency Sheet — Living Care Collective

Fill Your Emergency Sheet — Living Care Collective

Living Care Collective

Emergency Information Form

Person

Access

Medical

Contacts

Review

Step 1 of 4

About your loved one

Basic information about the person receiving care.

Personal Details

Full Name *

Date of Birth *

Phone Number

Home Address *

City

Province / Postal Code

Mobility Aids

Languages Spoken

Preferred Name

Additional Notes e.g. hearing aid, cognitive considerations, specific routines

Step 2 of 4

Home & access

How emergency responders and your coordinator can enter the home.

Entry Details

Entry Method *

Building / Complex Name

Unit / Suite Number

Building Manager

Manager Name

Manager Phone

Spare Key Holder

Key Holder Name

Key Holder Phone

Step 3 of 4

Medical information

Critical health details for emergency responders.

Health Details

Allergies

Current Medications (brief summary) Don't list every drug — just what a first responder needs to know quickly.

DNR / Advance Care Plan on file?

No Yes

DNR / ACP Location

Physician

Physician Name

Physician Phone

Pharmacy

Pharmacy Phone

Step 4 of 4

Emergency contacts

Two people we can reach when something unexpected happens.

First Contact

Name *

Relationship *

Mobile *

Home Access

Second Contact

Name

Relationship

Mobile

Home Access

All done

Review your sheet

Check everything looks right, then print or bring this to your first visit.

Living Care Collective

Emergency Information Sheet

—

Client

Address

—

Phone

—

Mobility

—

Home Access

Entry

—

Building Manager

—

Medical

Allergies

—

DNR

—

Physician

—

First Contact

Name

—

Relationship

—

Mobile

—

Access

—

Second Contact

Name

—

Relationship

—

Mobile

—

Notes

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Living Care Collective lccvancouver.com

Bring this to your first session or send a photo to your coordinator. They will complete the official sheet with you during that visit.

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