in the Town of Eden

TOWN OF EDEN EMERGENCY RESPONSE FORM

In the event of an emergency, if you or someone in your family is dependent on life support equipment or may be in need of special care, please fill out the following form. The Town of Eden Disaster Preparedness Committee will contact the person upon the receipt of the following information. If the Town's resident medical record has changed significantly, please fill out the form again. All information is strictly voluntary and will be kept confidential.

If you have any questions, please contact the Eden Disaster Preparedness Committee, or call 716 992-9211.

(* indicates required field)

Personal Information
*First Name:
*Last Name:
*Street:
*City:
State:
Zip Code:
*Home Phone:
E-Mail Address:
*Gender:	Male Female
Age:
Doctor
Doctor's Phone
Emergency Contact: (family or friend)
Emergency Phone:
Description of Disability:

Health Specifications
*Resuscitation	Yes No
Health Care Proxy	Yes No
Confined to Home	Yes No
Confined to Wheelchair	Yes No

Medical History
Please check all that apply	Blind Cardiac Stroke Diabetic Hypertension Cancer Asthma
Do you need attention during a power loss (Oxygen, Dialysis, Life Support)	Yes No
Medications
Comments or Special Needs

Town of Eden, Town Hall, 2795 East Church Street, Eden, New York 14057
Phone: 716 992-3408 Fax: 716 992-4131 Contact Us

Web design, computer program and content: Copyright 2006 Mary Lou Pew, with grateful appreciation for the technical support, graphical & web design of the University at Buffalo's WNY Regional Information Network. © Copyright 2006 Town of Eden, All rights reserved;Town of Eden Disclaimer Notice