Smiley Australia




Emergency Information List


MY NAME:	  ________________________

PHONE NUMBER:     Home:   ________________

		  Mobile: ________________

MY ADDRESS:
    Street Number & Name   ________________________

    Suburb/Town            ________________________

    Postcode		   ___________

    Melway Map Reference   ___________

    Nearest Cross Road     ________________________

    Other Landmarks or	   ____________________________________
    Identifying Features
			   ____________________________________


MEDICATIONS I AM TAKING:

    Name  ________________________  Dosage ____________mg

    Name  ________________________  Dosage ____________mg

    Name  ________________________  Dosage ____________mg

    Name  ________________________  Dosage ____________mg




MEDICATIONS I AM ALLERGIC TO:

    Name  ________________________  Dosage ____________mg

    Name  ________________________  Dosage ____________mg

    Name  ________________________  Dosage ____________mg








PERSONAL CONTACTS IN CASE OF EMERGENCY:




FIRST PERSON TO CONTACT ON MY BEHALF:


NAME:	  ________________________

PHONE NUMBER:     Home:     ________________

		  Mobile:   ________________

		  Work:     ________________

		  Address:  ________________________
	
		            ________________________

    		  	    ________________________



SECOND PERSON TO CONTACT ON MY BEHALF:
(If first person not available)


NAME:	  ________________________

PHONE NUMBER:     Home:     ________________

		  Mobile:   ________________

		  Work:     ________________

		  Address:  ________________________
	
		            ________________________

    		  	    ________________________


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