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Brevard County Fire Rescue
Vial of Life
-Personal Information-
*Name:_____________________________________
Address: ____________________________________
Phone: __________________*DOB:_____________
*Birth Sex: Male or Female or Intersex
*Weight: ________ Race: __________
Primary Language: ___________________________
Religion: ___________________________________
Social Security Number: _______________________
Doctor’s Name & Phone: ______________________
Are you a Military Veteran?____________________
-IN CASE OF EMERGENCY FIRST NOTIFY-
Name:_____________________________________
Address: ____________________________________
Phone: ____________________ Relation: ________
Name:______________________________________
Address:____________________________________
Phone: ____________________ Relation: _________
-INSURANCE COVERAGE -
Insurance Name:______________________________
Policy #:_____________________________________
Secondary Insurance Name:_____________________
Secondary Policy #: ___________________________
-CARE TEAM-
Court Appointed Guardian:_____________________
Phone #:______________________________
Healthcare Decision Maker: ____________________
Phone #:______________________________
Do you have a DNR?____________________
Do you have a Living will?________________
If yes to either, where?__________________
Attorney: ______________Phone #:______________
Financial Decision Maker: ______________________
Bank Name and Branch:__________________
Bank Name and Branch:__________________
Emergency Pet Sitter:__________________________
Phone #:______________________________
Type and Number of pets:________________
Veterinarian:__________________________
Do you have any dependents?__________________
If yes please list:________________________
Emergency Caretaker:___________________
Phone #: _____________________________
*Anything notated with an asterisk (*) is time
critical for emergency medical personnel.
*Allergies:____________________________________
*Current medications or supplements:
Medication or supplement Dosage Frequency
If you have more than 5 medications or
supplements please attach a separate sheet
(You can request a current list of prescriptions from
your doctor or pharmacy)
*Medication Locations:________________________
Blood Type: ______
Are you an Organ Donor? _____
*Please mark if you are
Mute Deaf Blind-Left/Right[___]
*Please mark if you use one of the following:
Glasses Contacts Hearing Aid
Upper Dentures Lower Dentures
Mobility Aid [Type__________]
*Please mark if you have even been treated for:
AIDS/HIV Positive Epilepsy
Anemia Glaucoma
Anxiety Heart Condition
Arthritis Hepatitis-Type [___]
Asthma High Blood Pressure
Cancer Migraines
COPD Pacemaker
Dementia Sickle Cell
Depression Stroke
Dialysis Tuberculosis
Diabetes
Other conditions not listed (including mental
health):_______________________________________
-Brevard County Fire Rescue does not affiliate with
any other agency-
To obtain a new form go to:
www.brevardfl.gov/FireRescue/EMSOps/VialOfLife
