Emergency Information Form
for Children with Special needs
This information form should be filled out by the child’s attending pediatrician, or in some cases, by another physician responsible for the child’s on-going care. The information form is aimed at children who have chronic illnesses and are likely to require treatment by paramedics and/or in an emergency department. The information form is designed to make important medical information rapidly available to paramedics and emergency department physicians.Once the information form is filled out, it should be kept in the child’s home where it will be readily accessible to rescuers (perhaps on the refrigerator). Families should be encouraged to carry a second copy with them, and have one with the child if away from the parents. It is the family’s responsibility to keep the form up-to-date, or to have the child’s physician update the form.
Please copy or download the information form on pink paper for distribution. Paramedics are being taught to look for a pink form in the home. Pink is for pediatrics (children).
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