SET Form Emergency Details

Emergency Medical Information

It is recommended that you keep a copy of this form in a prominent pace where it can be easily found in case of an emergency.

Note: One form should be completed PER OCCUPANT

A printable copy of your form will be emailed to you after this form is submitted.

A: OWNER/TENANT

Owner Tenant

Village:

Settlers Settlers Rest

Unit No:

Surname:

Full Names:

ID No:

Phone (Landline)

Cell number

Email:

B: MEDICAL INFORMATION

Medical Aid Name:

Membership Number:

House Doctor:

Doctor Telephone:

Allergies:

Blood Type:

May we call an Ambulance?

Yes No

Are you on Alderson's Database?

Yes No

Preferred Ambulance Service

Living Will

Yes No

If you have a Living Will, it is suggested that you attach it to this form when you print it.

Burial Wishes

Burial Cremation

Funeral Policy

Yes No

Undertaker

Current Medical Conditions

Current Medication:

Important Operations:

Any other information you feel we need to know:

B: SPOUSE/PARTNER

Yes No

Surname:

Full Names:

Relationship:

Telephone(s):

C: Next of kin not living with you

Next of kin, other than spouse/partner:

Relationship:

Telephone(s):

Date Submitted:

A printable copy of your notification will be emailed to you after this form is submitted.

I certify that the above information is true and correct.

Yes

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