HomeMy WebLinkAbout0007_2_Vial of Life Program - Exhibit A Cover Sheet and Form
Vial of Life Program
What is the Vial of Life?
The Vial of Life is a national project being implemented in the City of Lake Elsinore. It is a plastic
container that holds potentially life-saving information if you are found unconscious or unable
to communicate with emergency medical personnel. In a medical emergency even if you are
conscious or able to speak, you may not be able to provide or remember all pertinent
information needed in order for medical personnel to begin treatment immediately. Those few
minutes may save your life or the life of someone you love. The Vial of Life was created as a way
to organize this vital information in one convenient place. The Vial of Life Project is a charitable
non-profit organization that provides a life-saving option throughout the entire United States.
What’s in the Vial of Life?
The Vial of Life should contain all vital medical information for each person in your household
including current medications, allergies, ailments, emergency contact person, primary physician
and any advance directives in a location that is easily accessible for emergency personnel during
a health-related crisis or accident. One form should be used for each person in the household.
How do I use and store the Vial of Life?
Using a pencil, complete the Vial of Life Form with all pertinent information and place it in the
container. Emergency medical personnel are trained to locate a Vial of Life within your home.
The Vial of Life has a magnet attached to the backside of the container and is designed to be
magnetically attached to your refrigerator.
How to acquire the Vial of Life form and/or container?
The City of Lake Elsinore offers the Vial of Life forms and containers at no charge to residents.
They can be picked up at City Hall, local Fire Stations, the Lake Community Center and/or the
Senior Center. You can also visit www.lake-elsinore.org or call (951) 674-3124 ext. 314.
What is a DNR?
A DNR is a “Do Not Resuscitate” order form for a patient that does not wish to be revived after
their heart has stopped. The DNR form must be signed by a physician and must be present at
the scene and given to emergency personnel in order to be valid. We recommend that the DNR
form be placed in a location that is easily accessible.
Vial of Life Form
(Use a pencil to fill out this form)
Name: ________________________________ Document was last updated on: ___________
Address: _____________________________________ Phone: (_____) __________________
City: _________________________________________ State: _________ Zip: ___________
Date of Birth: _____________________Gender: F or M Height: _______ Weight: ________
Doctor’s Name: _________________________________ Phone (_____) _________________
Emergency Contact: ______________________________ Phone (_____) _________________
Insurance Company: ______________________________ Policy #: _____________________
Do you have a “DNR” Do Not Resuscitate order? Yes or No
If yes, where is it located? _________________________________
Do you wear? Dentures: Yes / No Glasses: Yes / No Contacts: Yes / No
(Circle)
Oxygen: Yes / No Hearing Aids: Yes / No
Medical History: (Circle medical conditions that apply)
Heart Attack Pacemaker Irregular Heartbeat Seizure Stroke Diabetes
Asthma Anemia Bleeding/Clotting Disorder Blood Pressure: High / Low
Tuberculosis Hepatitis HIV / AIDS Cancer (list type): _____________________________
Other Conditions: _____________________________________________________________
Current Medications: __________________________________________________________
____________________________________________________________________________
Allergies to Medications: _______________________________________________________
Surgeries in the last 5 years: ____________________________________________________
____________________________________________________________________________
Other Important Information: ___________________________________________________
____________________________________________________________________________
___________________________________________________________________________
(Use back of the page for any additional information)