To submit this form, you can send it via email to the designated medical professional or caregiver. Alternatively, you can fax the form to the given fax number or submit it through an online submission form if available. For physical submissions, mail the form to the relevant healthcare facility or emergency department. Be sure to keep a copy of the completed form for your records.

Ensure to review and update this form annually or whenever there are significant changes in the child's medical condition.

The purpose of the Emergency Information Form for Children with Special Needs is to ensure that important medical details are readily available in case of emergencies. This form helps parents, caregivers, and medical professionals provide timely and accurate information to emergency responders. By having this information on hand, responders can make informed decisions and provide the best care possible.

• 1. Last name: Enter the child's last name.
• 2. First name: Enter the child's first name.
• 3. Home Address: Enter the child's home address.
• 4. Parent/Guardian: Enter the parent or guardian's name.
• 5. Signature/Consent: Parent or guardian's signature and consent.
• 6. Primary Language: Enter the child's primary language.
• 7. Physicians: Details about the primary care physician and specialty physicians involved in the child's care.
• 8. Diagnoses/Past Procedures/Physical Exam: Information about the child's diagnoses, past procedures, and physical examination findings.
• 9. Medications: List of medications the child is currently taking.
• 10. Allergies: Details about medication and food allergies.
• 11. Procedures to be avoided: List any medical procedures that should be avoided for the child.
• 12. Immunizations: Information about the child's immunization status.
• 13. Antibiotic prophylaxis: Details about any antibiotic prophylaxis, including the indication and dosage.
• 14. Common Presenting Problems/Findings With Specific Suggested Managements: Information about common medical problems the child may present with and suggested management strategies.
• 15. Treatment Considerations: Specific treatment considerations for the child's medical care.

Failure to submit this form may result in delays in emergency care and inadequate treatment for the child with special needs. It is crucial to keep this form updated and readily accessible.

• Delayed Emergency Care: Emergency responders may not have access to vital medical information, resulting in delayed treatment.
• Inadequate Treatment: Without accurate information, the child may receive inadequate or inappropriate medical care.
• Increased Risk: The absence of critical medical details can increase the risk of complications during emergency situations.

• 1. Medical Emergencies: Provide essential information to emergency responders during medical emergencies.
• 2. School and Daycare: Ensure schools and daycare centers have all necessary medical information on file.
• 3. Caregiver Transition: Assist new caregivers in understanding the child's medical history and requirements.
• 4. Medical Appointments: Provide a comprehensive medical history to healthcare providers during appointments.
• 5. Travel: Carry essential medical information when traveling with the child.