Wales Center Volunteer Fire Company
12300 Big Tree Rd., PO Box 124, Wales Center, NY 14169-0124
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Public Safety > Calling for an Ambulance > Medical History and Drug Allergy form

  • Print this form.
  • Fill it out and keep it handy.
  • Be sure to keep the information current.
  • Give it to the EMS crew when they arrive.

WALES CENTER VOLUNTEER FIRE CO., INC.
Medical History and Drug Allergy Form

Name
Address
City State & Zip
Telephone Date of Birth
Primary Physician Hospital of Choice
Medical Problem(s)

 

 

 

 
Medicines (Prescription & Over the Counter)

 

 

 

 

 

 

 

 Allergies
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