Free face sheet template

The summary an emergency room asks for first. Fill it in, put one copy on the fridge and one in the go-bag, and give one to whoever drives to the hospital.

Keep it current in Agensy

Printing uses your browser’s print window, where you can also save it as a PDF. Nothing you type here is sent anywhere: the sheet is meant to be filled in by hand.

Tips from our care managers

Write medications exactly as they appear on the bottle.
Put allergies where nobody can miss them.
Date it. Redo it after every hospital stay or medication change.
Leave Social Security numbers off. A face sheet gets handed around.

Face sheet

Last updated: ______________

Allergies

Personal information

Full name

Preferred name

Date of birth

Phone

Address

Who to call

Name

Relationship

Phone

Care wishes

Code status

Advance directive on file? Where?

Preferred hospital

Medications

Medication

Dose

How often

For

Prescriber

Doctors

Name

Specialty

Phone

Diagnoses

Insurance and pharmacy

Medicare number

Part A / Part B start dates

Other insurance company

Member ID / group number

Pharmacy name

Pharmacy phone

Decision makers

Medical power of attorney (name, phone)

Durable power of attorney (name, phone)