Emergency Contact / Medical History Report

   
Customer Name
Customer Email
Company/Organization
Room Number
Green Village ID Number
   

Emergency Contact Information

   
Primary Contact - Name
Phone Number
Relation
Email Address
Secondary Contact -Name
Phone Number
Relation
Email Address
   

Health History

Please list any medication you are currently taking, health conditions or any information that may be useful in the event of Emergency treatment that should be helpful to a physician
 
 

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