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Town of Eden Emergency Notification 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