Filled Sample — Emergency Information Sheet
Living Care Collective
Emergency Information Sheet
Sample
Dorothy Callahan DOB March 14, 1947
Client
Home Address
42 Cedar Lane, Unit 3
North Vancouver, BC V7M 2K4
Phone
(604) 555-9201
Mobility
Walker / cane
Languages
English
Home Access
Entry Method
Lockbox — code 7842
Building Manager
Tom Vasquez
(604) 555-3300
Medical
Allergies
Penicillin — hives
DNR Status
Yes — copy in bedside drawer
Physician
Dr. Patricia Walsh
(604) 555-1234
Notes
Blood pressure medication — pill organizer on kitchen counter. Hearing aid, right ear.
First Contact
Name
James Callahan
Relationship
Son
Mobile
(604) 555-0847
Home Access
Has key
Second Contact
Name
Ruth Hendricks
Relationship
Friend & neighbour
Mobile
(604) 555-2193
Additional Notes
Prefers to be called Dorothy. Grocery delivery Thursdays. Key family contact: James handles all medical decisions.
Living Care Coordinator Claire Bennett · (604) 555-0142

This is a sample showing a completed Emergency Information Sheet.
Your coordinator will complete this with you at your first visit.