640 South State StreetDover, Delaware 19901
21 West Clarke AvenueMilford, Delaware 19963
401 North Carter RoadSmyrna, DE 19977
640 S. State StreetDover DE 1990121 West Clarke AvenueMilford DE 19963
301 Jefferson AveMilford, DE 19963
1275 S. State StreetDover, Delaware 19901
In an emergency, it is easy to "forget" even the most well-known information. That is why it is crucial for you to complete the information in this form for each member of your household. Then, distribute copies to each member of your household. Also, post all copies by each telephone and in easy to find places in your home, car, or work. Be sure to update the information often.
Also, make copies for non-resident relatives, babysitters, caretakers, neighbors, teachers -- anyone who has contact with you or who is periodically responsible for your children (or any disabled or older adults in your home).
If you own a cell phone, put 2 different contacts in your phone under ICE for 'in case of emergency,' so emergency room staff can call your contacts in the event you can not communicate. Examples could be ICE-mom or ICE-husband to identify your contact. Newer smartphones have apps that you can download to make this information easier to access. Do not rely on your smartphone however, as it may be out of power, overlooked or not on you at the time. It is still critical to have additional copies of this form.
Emergency transport system
(if 9-1-1 system is not available in your area)
Post the poison center telephone number by every telephone in your home. The national, toll-free poison control center locator number is: 800-222-1222.
From here, you will be automatically redirected to the nearest Poison Center in your area.
Hospital emergency room
Person's full name
Date of birth
at last physical in:
at last physical in:
Directions to home
Contact person #1
Work or home address
Contact person #2
Contact person #3
Bayhealth is Southern Delaware’s healthcare leader with hospitals in Dover and in Milford. Bayhealth provides a wide range of medical services, including cardiovascular, cancer, orthopaedics and rehabilitation, pediatrics, respiratory care, sleep care, surgical weight loss and women’s services.