F EmerMedicalCare doc - the State of Connecticut Website 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the child's name and birthdate in the designated fields. Ensure accuracy as this information is crucial for emergency situations.
3. Fill in the parent's names along with their emergency contact numbers. This ensures that caregivers can reach someone quickly if needed.
4. Provide the home address, town, and zip code. This information helps identify your location during emergencies.
5. List any allergies your child may have and note the date of their last tetanus shot to inform medical personnel.
6. Enter details of the preferred medical facility and its phone number for quick access during emergencies.
7. Complete insurance information, including carrier and ID number, to facilitate coverage during medical visits.
8. Designate a physician to be contacted in case of an emergency by filling out their name, phone number, and address.
9. Sign and print your name at the bottom of the form, along with the date. This confirms your consent for emergency medical care as outlined.

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