Emergency Information Sheet

Smart Med Alert
1955 Milestone Dr, Suite E, Salt Lake City, UT 84104
Phone: (866) 339-3827

Complete one form for each medical alert device user. Provide information that may be important during an emergency response.

Fields marked are required.

1. Customer and service location
Submission type
2. Emergency contacts

Please provide at least two emergency contacts when possible. List the contacts in the order they should be contacted.

Contact 1
Contact 2
Contact 3
Contact 4
Contact 5
3. Information important during an emergency

List only conditions that may be important during emergency response. If none, write “None.”

Include medication, food, latex, or other severe allergies and describe the known reaction when possible. If none, write “None.”

Include information emergency responders may need to know, such as limited mobility, wheelchair or walker use, hearing or speech needs, memory loss, oxygen in the home, household pets, or other responder-safety information.

4. Emergency entry information

If the primary entrance is locked, how may emergency personnel enter? Check all that apply.

Emergency entry methods

Provide only information necessary for emergency access. This information may be shared with the monitoring center and emergency responders when needed.

5. Customer confirmation