Client Emergency Information
Clients Full Name:
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Clients Address:
*
Street Address
City
Unit & entry details
State / Province
Type of Address:
Please Select
Home
Apartment
Long Term Care Home
Retirement Home
Hospital
Primary Language Spoken
Code Status & Directives
CLIENTS CODE STATUS:
*
Do not attempt CPR (Legal DNR order in place)
No DNR order in place (CPR)
Location of Do Not Resuscitate (DNR) form
Allergies & Critical Alerts
Allergies:
*
Life-threatening allergies (drug/food/latex; reaction)
Infection precautions:
(e.g., C. diff history) if relevant for PPE
High-risk flags:
(anticoagulants, severe fall risk, choking risk, wandering)
Emergency Contacts
Primary Decision Maker (POA):
*
First Name
Last Name
Relation:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact:
First Name
Last Name
Relation:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Disaster Preparedness
(If applicable)
First Aid Kit Location
Fire Extinguisher Location
Nearest Exits
Water Shutoff Location
Water Heater Location
Gas Shutoff Location
Electrical Panel Location
I understand that this information will be stored as part of the care profile and shared with caregivers and internal Senior Support Care staff to ensure safety and continuity of care.In the event of a medical emergency, this information may also be shared with paramedics, medical professionals, or emergency responders to provide appropriate and timely care.
*
Full Name
Date of Consent
*
-
Month
-
Day
Year
Date
Save
Submit
Should be Empty: