Child’s full name:__________________________ Age:_____________

Physicians name and number:_________________________________

Number parents can be reached in emergency:____________________

The syrup of ipecac is located:_________________________________

Weight:_______________ Allergies:____________________________

Medical conditions:__________________________________________

_________________________________________________________

Current medications(including dose and times given):

_________________________________________________________

_________________________________________________________

_________________________________________________________

Insurance/Medical record #___________________________________

Hospital name and number:___________________________________