Fill out the form, completing all the open fields:
Patient Demographic, including allergies
Known medical conditions. If not listed, please fill out specific medical history under “current or previous surgeries or conditions”. In this field, please identify if a valid DNR or Advanced Directive has been signed for the patient.
Complete Medication List. Provide current medications, dosages, and frequency of dosage (once daily, every 4 hours, etc.). Please update this information when prescription information changes.
Include appropriate information regarding Primary Care Physician, Insurance Provider, Emergency Contact Person, and all relevant phone numbers and identification numbers. This information is vital for Emergency Responders when providing care and transporting to hospitals.
If any assistance is required, contact the Piperton Fire Department at 901-853-2195 between the hours of 8:00 AM and 5:00 PM to schedule for personnel to perform a home visit and assist with documentation completion.
Print this document. Place this document and any appropriate copies of medical paperwork together, and place within document holder. This holder will be provided by the Piperton Fire Department. The document holder should be placed on your refrigerator for rapid access. This document may also be used during your routine visits with your healthcare provider. Feel free to take this form with you for reference or updates when visiting your physician.