PROCLAMATION No.2 - Prince Hall Grand Masonic Lodge of ...

Medical Information/Emergency Treatment Form
~arne
_
4~ge
_
Chaprer VVorthy~on ~-------- _
In case of an emergency, please contact the following
persons.
~arne ~ Rclationmnp _
Home Phone --,- _ Work Phone _
Addre~
_
Name _ Relationship _
Home Phone - _ VVorkPhone _
Address
_
I give my permission to be treated by the local hospital emergency room personnel.
yes
~ __
No_...._-----
The following is requested to assist our staff and the emergency medical treatment personnel.
:> List any medical problems that you have (i,e, high blood pressure, diabetes, etc):. _
>- List all medications that you are taking, the dosage, and time: _
>- List any allergies you may have to plants, insects, medicines. or others: _
Family Physician __ ~ _ Phone _
FamilyDenu& Phone --------------
Signattrre _ D~ _
All information provided is confidential and will be used as need.
Please return this form to:
Alice S. Blythe, Grand Chairperson of First Aid and Health
1649South Paxton Street,
PhiladelPhia~PA 19143