Vial of Life Information
Today's Date:_____________________
Name:___________________________
Date of Birth:____________________ Age:_________________
Soc. Sec. #:_____________________
Sex: Male_____ Female:_____
Physician's Name:_______________________
Phone:_____________________________
Hospital where records are kept:____________________________________
Name of Insurance:______________________________________________
Card#:_____________________________
Medicare #:____________________________
Medicaid #:____________________________
In Case of Emergency Contact:
1. __________________________________________
__________________________________________
__________________________________________
2.
__________________________________________
__________________________________________
__________________________________________
Supported by:
Lions Club, St. Clair County Council on Aging and Port Huron Hospital
Endorsed by all:
St. Clair County Hospitals, Emergency Medical Services, Fire Departments and Law Enforcement Agencies.