Personal Emergency Profile

Jane Sample

Medical Alerts / Conditions:

Anaphylaxis - If I have difficulty breathing, swelling on my face, wheezing, difficulty swallowing or rapid pulse I've been stung by a bee and could die: Get my epinephrine auto-injector in my purse or car, shoot in my outer thigh and get me to a hospital right away!


COVID-19 tested?: ( ) Yes() No

COVID-19 Vaccinated?: ( ) Yes() No

COVID-19 Vaccination Date:

Medical (RX) Presciptions:

Epinephrine injector - shoot in my outer thigh if I show any symptoms above!!!

Non Prescribed Drugs, Medications, Supplements:



Extremely allergic to bee stings!

Blood Type:

Blood Type: A Pos

Other Important Info:

I highly recommend getting your own medical alert stickers - very inexpensive, easy to set up and they can save your life. Go to and subscribe now!

Emergency Contact - 1:

Name: John Sample

Phone: 201-123-1234

Emergency Contact - 2:

Name: Anne Sample


Primary Care Physician:

Name: Dr. Alpha

Clinic: Fairview

Phone: 201-456-7890

Insurance Provider:

Carrier: Blue Cross

Subscriber / Policy #:3455-12333-4565

Group #: 314

Phone: 201-234-3456