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Health Care Binder

Emergency Information: Last Updated:

Emergency Numbers
Emergency: 911 Fire:
Poison Control: 1-800-222-1222 Pharmacy:
Ambulance:
Police:

Medical Numbers
Pediatrician’s name and #:
Dentist’s name and #:
Specialist’s name and #:

Notes:
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Health Care Binder

Child Information

Child’s Full Name:

Birth Date:
Address:

Phone Number: Blood Type:

Allergies:
Medical Conditions:
Notes:

Child’s Full Name:

Birth Date:
Address:

Phone Number: Blood Type:

Allergies:
Medical Conditions:
Notes:

Child’s Full Name:

Birth Date:
Address:

Phone Number: Blood Type:

Allergies:
Medical Conditions:
Notes:

Last Updated ______

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Health Care Binder

Parent Information

Mother’s Full Name:

Birth Date:
Address:

Phone Number: E-Mail:

Employer:
Work Address:
Work Phone: Work E-Mail:
Blood Type: Birth Date:
Allergies:
Medical Conditions:
Notes:

Father’s Full Name:

Birth Date:
Address:

Phone Number: E-Mail:

Employer:
Work Address:
Work Phone: Work E-Mail:
Blood Type: Birth Date:
Allergies:
Medical Conditions:
Notes:

Last Updated ______

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Health Care Binder

Health Insurance Provider – General Information

Primary Insurance Provider:

Group #: Policy #:
Phone Number: Fax:
Claims Address:
Policy Holder Name:
Policy Holder Employer & Birth Date:
Notes:

Secondary Insurance Provider:

Group #: Policy #:
Phone Number: Fax:
Claims Address:
Policy Holder Name:
Policy Holder Employer & Birth Date:
Notes:

Claims – Dates - Notes:

Last Updated ______

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Health Care Binder

Prescriptions
Date Filled: Co-Pay:
Name:
Write the full name that is on container label and the concentration (mg/L) or dosage amount (mg)

Dosing Directions:
Example: 15mls per day before bedtime.

Notes:

Date Filled: Co-Pay:

Name:
Write the full name that is on container label and the concentration (mg/L) or dosage amount (mg)

Dosing Directions:
Example: 15mls per day before bedtime.

Notes:

Date Filled: Co-Pay:

Name:
Write the full name that is on container label and the concentration (mg/L ) or dosage amount (mg)

Dosing Directions:
Example: 15mls per day before bedtime.

Notes:

Last Updated ______

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Health Care Binder

Appointments: Office, Urgent Care, Hospital & Emergency

Visits

Appointment Date: Purpose:

Doctor’s Name:
Diagnosis:

Co-Payment/Method of Payment:
Notes:

Appointment Date: Purpose:

Doctor’s Name:
Diagnosis:

Co-Payment/Method of Payment:
Notes:

Appointment Date: Purpose:

Doctor’s Name:
Diagnosis:

Co-Payment/Method of Payment:
Notes:

Last Updated ______