Individual Intake Resources Emergency Medical Information Emergency Medical Information "*" indicates required fields Name* First Last Date* MM slash DD slash YYYY Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Social Security Number*Birth Date* MM slash DD slash YYYY Physical State* Verbal Nonverbal Ambulatory Non-ambulatory Physical DescriptionRace* Height* Hair* Eyes* Weight* Distinguishing Marks*Medical Restrictions or Limitations*Date of Last Tetanus Shot* MM slash DD slash YYYY Medical InformationPrimary Diagnosis* Secondary Diagnosis* Medications*Allergies*Primary Emergency ContactName* First Last Relationship* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Secondary Emergency ContactName* First Last Relationship* Phone*Address* Street Address City State / Province / Region ZIP / Postal Code Preferred Treatment LocationHospital Name* Address* Street Address City State / Province / Region Physician Name* First Last Phone*Insurance Policy Number*Medical Authorization* I agreeI hereby consent and authorize the organization, its agents, and associates to provide service, care, and treatment to me in my home, the community, and/or a facility, as well as in emergency situations that may require hospital care. I have received an explanation of the services to be provided (including goals, outcomes, schedule of service), my involvement with the Person-Centered Individual Support Plan (PCISP), and how changes will be made if needed. I understand that I and/or my family/caregiver/guardian/spouse will be responsible for my care in absence of the staff provided by CDC Resources, Inc. By signing below, I give consent and authorization for CDC Resources, Inc. to provide support as outlined in my PCISP and seek medical treatment on my behalf in cases of illness, injury, or an emergency. I also consent for CDC Resources, Inc. to exchange information which may occur between, but is not limited to, physicians, other health care providers, government agencies, community organization or regulatory reviewers.Signature of Individual Served* Date* MM slash DD slash YYYY Signature of Parent/Guardian/Advocate/Spouse/Witness* Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged. Forms and Policies Individual Information and Intake Form Emergency Medical Information Information Release Policy On Resolving Consumer Complaints
