Member Emergency Profile

Personal Information

Date of Birth:

Not Provided

(dd/mm/yyyy)

Health Card Number: 

Full Name: 

Phone: 

Home Address: 

Blood Type: 

Unknown

Blood Pressure: 

Health Insurance: 

Unknown

Travel Insurance: 

Emergency Contact Details

Primary Contact

Name: 

Phone: 

Secondary Contact

Name: 

Phone: 

Family Doctor or Clinic Contact

Type: 

Name: 

Phone: 

Medical Conditions

Medical Conditions

None Listed

Other Medical Conditions

None Listed

Medication Information

Medication List

None Listed

Current Medication Details

None Listed

Known Medication Allergies

Medication Allergies

None Listed

Other Medication Allergies

None Listed

Other Allergies

Allergies

None Listed

Other Allergy Details

None Listed

General Medical Information

Miscellaneous

Do you smoke: 

Do you vape: 

Do you wear glasses: 

Do you wear contacts: 

Do you have cataracts: 

Are you pregnant: 

Other Medical Details

Vaccination Information

Common Vaccinations Details

Hepatitis A/B: 

Influenza: 

Pneumonia: 

Shingles: 

Tetanus: 

Other Vaccination Details

COVID Information

COVID Vaccination

Have you had COVID:

Have you been vaccinated: 

Covid Vaccination Reactions or other Details

COVID Booster

Have you had a COVID Booster:

Booster Type and Date: 

Existing Medical Conditions Preventing Vaccination