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Get Cpr Record Sheet

Print Personal Medical Record Name Date Address Phone Birthdate Do you have an EMS-No CPR Directive or a DNR form Yes No Where is it Do you have a Health Care Advanced Directive Agent s Name Medical Conditions Allergies Drug Reactions Doctor Pharmacy Contacts Doctor s Name Pharmacy Name Emergency Contacts Relationship - Keep this card in your wallet or purse. - Keep the information on it up-to-date. - Post a copy in a visible place in your home like on your refrigerator. - For additional copies of this form contact your local Area Agency on Aging see other side or call the Virginia Department for the Aging tollfree at 1-800-552-3402 Voice/TTY. - Keep the information on it up-to-date. - Post a copy in a visible place in your home like on your refrigerator. - For additional copies of this form contact your local Area Agency on Aging see other side or call the Virginia Department for the Aging tollfree at 1-800-552-3402 Voice/TTY.

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