Emergency Information Form for Children With Special Needs

Once submitting the form, Upper Pine River Fire EMS personnel will make an appointment to visit your home to cover any specifics, observe your child in their normal state and get familiar with any technology such as ventilators, feeding systems and ports.

The information on this form is protected by the Health Insurance Portability and Accountability Act of 1996 privacy provisions. Portions of this information may be shared with Emergency Management Official in the event of a Natural disaster or evacuation due to wildfire.

PLEASE COMPLETE:

We encourage you to submit your information directly to our database by using the online form below, but you may also download a hard copy of the form to fill out and either email to ems@upperpinefpd.org or bring it by the Administration building at 515 Sower Dr, Bayfield, (970) 884-9508.

PHYSICIANS:

DIAGNOSIS/PAST PROCEDURES/PHYSICAL EXAM:

MANAGEMENT DATA:

IMMUNIZATION DATES (mm/yy):

DPT:

OPV:

MMR:

HIB:

HEP B:

Varicella:

TB Status:

Other:

COMMON PROBLEMS/FINDINGS WITH SPECIFIC SUGGESTED MANAGEMENTS:

COMMENTS ON CHILD, FAMILY, OR OTHER SPECIFIC MEDICAL ISSUES: