A 3-page emergency sheet meant for the refrigerator or a labeled pouch, so responders and covering staff can see alerts fast.

For a USA non-medical home care agency to leave in the client’s home. You get one editable Word file.

What’s included

1. Page 1: identity, an optional photo box, critical alerts for EMS, emergency contacts, preferred hospital, and a short baseline note
2. Page 2: medication list, allergies and reactions, conditions, devices, and recent hospital stays
3. Page 3: providers, insurance without a Social Security number, home access notes, and a review log

Add your logo and name

1. Open the Word file and replace the Agency Logo box with your logo.
2. Replace Agency Name, and add your on-call and office lines where the sheet asks for them.
3. Save, print a copy to post in the home, and update the review log when something changes.

Editable template for your agency to adapt. Not legal advice, not a license to operate, and not HIPAA software. This sheet is not a DNR or POLST, and it is not medical advice. Match it to your state rules, and do not put a Social Security number on it.