(Fold this form and keep it in your wallet) 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information in the designated fields, including your name, phone number, and birth date. This ensures that your medical details are easily accessible.
3. Fill out the emergency contact section with names and phone numbers of individuals who can be reached in case of an emergency.
4. Record your retail pharmacy's name and phone number for quick reference when needed.
5. In the immunization record section, document the month and year of your last pneumonia and flu vaccine doses. If you’re unsure, consult your medical records.
6. List all medications you are currently taking, including prescription drugs, over-the-counter medications, and herbal supplements. Be sure to include dosage, frequency, and reasons for taking each medication.
7. Document any allergies you have along with a description of reactions experienced. This is crucial for healthcare providers.
8. Finally, ensure that you save your completed form securely within our platform so it can be accessed anytime you need it.

Start using our platform today to keep your health information organized and accessible!