In Case of Emergency (ICE)

 

This information is to be used in the event of a medical emergency ONLY and not to be used for personal information or to contact me for future bookings. Always contact the agency which you originally hired me from.

 

ALLERGIES:

 

• Medicine:
• Nature (bugs, bushes, food, etc.):
• Man Made (latex, etc.)

 

PRIMARY QUICK NEED INFORMATION:

 

• Birth date
• Major Medical Issues

• Minor Medical Issues
• Internal/External Health Items (pacemaker, hearing aid, etc.)
• See list of prescribed and OTC medicine listed later on form (yes / no)
• See list of surgeries listed later on form (yes / no)

 

IF YOU ARE FEMALE AND PREGNANT:

 

Any information necessary: including OB/GYN, complications, risk factors, due date.

 

SECONDARY QUICK NEED INFORMATION:

 

• Primary Language and Secondary Language
• Blood Type

• State Advanced Health Care Form is on file at _________ hospital or found at ____________
• Power of Attorney Form is on file at _________ or found at _________ (CA no longer uses this form for medical and instead uses the CA Advanced Health Care Form) which means the Power of Attorney is used only for legal and financial matters in CA.
• Statement of Authorized Representative is on file at _________ hospital. (Cheryl –form creator – personal note: Kaiser has mine on file for my three ICE contacts along with my State Advanced Health Care Form, but I do not know if other places require this form or not).

 

ORGAN DONOR:

 

I have a signed organ donor card located at ______________ please inform the doctor / ambulance / hospital so they can honor those wishes.

 

RELIGION:

 

I practice ______________ and please inform the doctor/ambulance/hospital so they can honor those wishes.

 

PLACE OF WORSHIP:

 

I wish for you to contact the following congregation I am a member of:

 

PERSONAL INFORMATION:

 

Full Real Name

Physical Living Residence

Mailing Address

Home Number

Office Number

Cell Number

Car Key (where I put my key when I perform)

Vehicle Information (year/make/model/color/license #) – (so you can find it parked in the area)

Driver’s License Number

 

EMERGENCY CONTACT PERSON #1:

 

Full Real Name

Relationship to You

Physical Living Residence

Home Number

Office Number

Cell Number

EMERGENCY CONTACT PERSON #2:

 

Full Real Name

Relationship to You

Physical Living Residence

Home Number

Office Number

Cell Number

 

EMERGENCY CONTACT PERSON #3:

 

Full Real Name

Relationship to You

Physical Living Residence

Home Number

Office Number

Cell Number

 

PRIMARY MEDICAL INSURANCE CARRIER:

 

Name

Membership Number

Group Number

Emergency Contact Phone Number

 

PRIMARY DENTAL INSURANCE CARRIER:

 

Name

Membership Number

Group Number

Emergency Contact Phone Number

 

PRIMARY VISION INSURANCE CARRIER:

 

Name

Membership Number

Group Number

Emergency Contact Phone Number

 

PRIMARY CHIROPRACTOR INSURANCE CARRIER:

 

Name

Membership Number

Group Number

Emergency Contact Phone Number

 

ADDITIONAL Medical Contacts I see:

 

Name

Membership Number

Group Number

Emergency Contact Phone Number

 

AUTOMOBILE HANDICAP PLACARD:

 

I have one (yes/no)

It may be hanging on my mirror, but if not, where is it when NOT in use

Where is authorization form kept

 

SURGERY LIST:

 

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PRESCRIBED MEDICINE LIST:

 

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OTC MEDICINE/VITAMIN/SUPPLEMENT LIST:

 

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END OF ICE FORM