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Lhcaz docs default-sourceAdditional Health Information & Epi-Pen Form

Lhcaz docs default-sourceAdditional Health Information & Epi-Pen Form 2025

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4.8 out of 5

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The document is a health information and Epi-Pen form for participants of programs organized by the Lake Havasu City Fire Department. It collects essential medical details, including allergies, medical conditions, and emergency treatment protocols related to anaphylaxis. The form outlines requirements for Epi-Pen provision and administration, as well as a waiver releasing the city from liability regarding Epi-Pen use.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the Participant Name and Health Insurance Provider details. Ensure that you include the Plan or Group number for accurate identification.
Fill in the Participant’s Physician name and their contact number. This information is crucial for any medical inquiries.
Proceed to the Medical Conditions/Behavioral Issues section. Answer each question regarding conditions like Asthma, Hypertension, and Diabetes by selecting 'Yes' or 'No'. If applicable, provide additional details in the space provided.
In the Allergies section, indicate if there are any life-threatening allergies. List specific triggers and symptoms to ensure proper care.
Complete the Epi-Pen Requirements by initialing each requirement to confirm understanding and compliance. Fill in expiration dates for Epi-Pens as needed.
Finally, sign at the bottom of the form as a Participant/Parent/Legal Guardian to validate all provided information.

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