Personal Emergency Profile Form PDF Details

In today's fast-paced world, being prepared for emergencies has become a necessity, particularly for those with health concerns or in need of swift assistance. The 5Star Personal Profile form embodies this principle of preparedness, serving as a crucial tool for ensuring that essential information is at hand when most needed. This comprehensive form is designed for users to input information that GreatCall agents can utilize in emergency situations to provide timely and effective aid. Users are encouraged to fill out both sides of the worksheet, detailing basic personal information, such as name, contact details, language, ethnicity, and gender, alongside more specific data like frequent locations, emergency contacts, medical details, and vehicle information. This form not only includes sections for listing medications, medical conditions, and allergies but also facilitates the inclusion of doctors' contacts and preferred hospitals, ensuring that personal health needs are clearly communicated in critical times. Submission of the completed form is made convenient through three methods: online, mail, or fax, emphasizing the importance of accessibility and efficiency in emergency preparedness. Moreover, the form's design reflects a deep understanding of the complexities and nuances of personal health and safety, aiming to provide a tailored response in emergencies by keeping the profile information confidential and securely stored, only to be shared with emergency personnel when necessary. Thus, the 5Star Personal Profile form stands as a testament to the importance of staying prepared, offering peace of mind and a layer of protection for its users.

QuestionAnswer
Form NamePersonal Emergency Profile Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespersonal emergency profile, greatcall com login, profile form, mygreatcall

Form Preview Example

5Star Personal Profile Form

IMPORTANT! Please complete

Please complete the front and back of this worksheet with the information you would like GreatCall’s Agents to be prepared with in the case of an emergency. Once complete, submit the information to GreatCall in one of three easy ways:

1.Visit mygreatcall.com and submit your information online.

2.Mail the form to: GreatCall, Inc. | Attn: 5Star Account Support | P.O. Box 4428 | Carlsbad, CA 92018

3.Fax the form to the 5Star Account Support team at 1-760-438-9790

Basic Information

Your Name:

Home Phone:

Your Email:

What language do you speak?

What is your ethnicity? (check one)

African American Caucasian

American Indian or Alaskan Native Asian

Native Hawaiian or Other Paci

Other

Gender Male Female

Date of Birth

 

Locations

The following information can help us track your location faster. Please provide locations you visit frequently (e.g. of

Location 1:

Name (e.g. “of

Address:City/State/Zip

Phone:

Additional information (e.g. gate security code/hidden door key):

Location 2:

Name (e.g. “gym”):

Address:

 

 

City/State/Zip

 

Phone:

 

 

 

 

 

 

Additional information (e.g. gate security code/hidden door key):

 

Emergency Contacts (Emergency contacts will only be called at subscriber’s request)

 

 

 

 

 

 

 

 

 

Emergency Contact 1:

 

 

 

 

 

Full Name:

 

 

 

 

 

 

Relationship (e.g. spouse):

 

 

 

 

 

 

Address:

 

City/State/Zip

 

Phone:

 

 

Phone 2:

 

Does this person live with you? Yes No

 

 

 

 

 

Is this person authorized to make changes to your pro

Yes No

Is this person authorized to call 5Star on your behalf in case of an emergency? Yes No When calling 5Star, this authorized contact will be asked to provide the following security pass phrase:

PLEASE CONTINUE TO THE BACK SIDE OF THIS FORM >>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>

5STAR-INS-PP-V1

5Star Personal Profile Form – continued

Emergency Contacts (Emergency contacts will only be called at subscriber’s request)

Emergency Contact 2:

Full Name:

Relationship (e.g. spouse):

 

 

 

 

Address:

 

 

City/State/Zip

 

Phone:

 

Phone 2:

 

Does this person live with you? Yes No

 

 

 

Is this person authorized to make changes to your pro

Yes No

Is this person authorized to call 5Star on your behalf in case of an emergency? Yes No

When calling 5Star, this authorized contact will be asked to provide the following security pass phrase:

 

 

 

 

 

 

 

 

Medical Information

The following information will help emergency responders in case of a medical crisis.

Medication Name/Dosage/Unit/Instructions: 1.

2.

3.

4.

5.

Medical/Physical Conditions (e.g. disabilities, diabetes, COPD, high blood pressure)

 

 

1.

 

 

 

 

 

 

 

 

 

 

Is this an allergy

Yes

No

2.

 

 

 

 

 

 

 

 

 

 

Is this an allergy

Yes

No

3.

 

 

 

 

 

 

 

 

 

 

Is this an allergy

Yes

No

4.

 

 

 

 

 

 

 

 

 

 

Is this an allergy

Yes

No

5.

 

 

 

 

 

 

 

 

 

 

Is this an allergy

Yes

No

Doctors and Hospitals

 

 

 

 

 

 

Doctor’s Full Name:

 

 

 

 

 

 

 

Type of Doctor:

 

 

 

 

 

 

 

Hospital:

 

 

 

 

 

 

 

Address:

 

City/State/Zip:

 

 

 

Phone:

 

Phone 2:

 

 

 

Email:

 

 

 

 

 

 

 

Vehicles

Vehicle 1

Year:

 

Make:

 

Model:

 

Color:

 

 

 

License Plate:

 

 

 

State:

 

Vehicle 2

 

 

 

 

 

 

 

 

Year:

 

Make:

 

Model:

 

Color:

 

 

 

License Plate:

 

 

 

State:

 

5Star Service and the Personal Profile are limited to one user per subscription and cannot be shared with another person. The profile information you provide is personal to you and could be critical in assisting you in an emergency. We keep your profile confidential using a secure datacenter, and we only share your information with emergency personnel in the event of a critical situation.

How to Edit Personal Emergency Profile Form Online for Free

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Step 1: Open the form inside our tool by clicking on the "Get Form Button" above on this page.

Step 2: As you start the file editor, you'll notice the document prepared to be filled in. Aside from filling in different fields, you can also do other sorts of things with the PDF, namely writing custom words, modifying the original text, inserting illustrations or photos, putting your signature on the form, and much more.

As for the blank fields of this particular form, this is what you want to do:

1. The greatcall com login necessitates particular information to be inserted. Ensure the following fields are completed:

Filling in section 1 of 2006 txr01 sales use form online

2. Right after filling in the last step, go on to the next stage and complete all required particulars in all these fields - Location Name eg ofcidce Address, CityStateZip, Emergency Contacts Emergency, Emergency Contact Full Name, Please continue to the back side, and STARINSPPV.

Emergency Contacts Emergency, Emergency Contact Full Name, and STARINSPPV of 2006 txr01 sales use form online

3. The following part focuses on Emergency Contact Full Name, Medical Information, The following information will, and Medication - complete these blanks.

Completing section 3 in 2006 txr01 sales use form online

4. This specific section arrives with the following form blanks to type in your specifics in: MedicalPhysical Conditions eg, Is this an allergy Yes No Is, Doctors and Hospitals Doctors Full, CityStateZip Phone, Vehicles, Vehicle Year Color Vehicle Year, Make, License Plate, Model, and State.

Part no. 4 in filling out 2006 txr01 sales use form online

5. This pdf should be finalized by going through this segment. Below you have a comprehensive set of form fields that require specific details in order for your form submission to be faultless: Vehicle Year Color Vehicle Year, Make, License Plate, Model, State, and Star Service and the Personal.

Part no. 5 for filling in 2006 txr01 sales use form online

It is easy to make errors when filling in the State, and so make sure that you reread it before you decide to send it in.

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