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Medwaiver (Lake Havasu City)

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File type: PDF

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LAKE HAVASU CITY FIRE DEPARTMENT
2330 McCulloch Blvd. N.
Lake Havasu City, AZ 86403
(928) 855-1141 lhcfire@lhcaz.gov
Additional Health Information & Epi-Pen Form
FD-288A Updated/CA 10-01-2019 Page 1 of 2
Participant Name:
Health Insurance Provider:
Plan or Group #
Participant’s Physician:
Phone #
Medical Conditions/Behavioral Issues
Yes
No
If yes, is the Participant’s asthma exercise induced?
Yes
No
Does the Participant carry a rescue inhaler?
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
If yes, describe the behavioral issue, triggers, and suggestions for assisting Participant:
Yes
No
If yes, describe the medical conditions:
Please list any medication the Participant is currently taking and why:
(Attach Additional Sheet if Necessary)
Allergies
Does the Participant have any life threatening allergies? (food, medication, plants, animals, insects, etc.) Yes No
Participant’s anaphylaxis triggers are:
Peanuts
Nuts
All Dairy
Eggs
Shellfish
Fish
Food Additives, list:
Insects/Bites, list:
Medications, list:
Other, list:
FD-288A Updated/CA 10-01-2019 Page 2 of 2
Participant’s anaphylaxis symptoms usually are:
Swelling (eyes, lips, face, tongue)
Coughing/Choking
Difficulty Breathing/Swallowing
Vomiting
Stomach Cramps/Diarrhea
Flushed Face/Body
Dizziness/Confusion
Change of Voice
Fainting/Loss of Consciousness
Cold, Clammy, Sweaty Skin
Other, list:
Participant’s emergency treatment is:
Anti-histamine (list precise measuring instrument, specific brand, and dosage):
Epi-Pen
Other, list:
EPI-PEN REQUIREMENTS:
(Initial after each of the below listed requirements)
- Participant must provide the program with two, non-expired Epi-Pens (initials) _________
- Epi-Pens must be in original container with appropriate label intact (initials) _________
- Participant must be trained to administer an Epi-Pen without assistance (initials) _________
Epi-Pens Expiration Dates: ____ / _____ / _____ ____ / _____ / _____
Number of times the Participant has used an Epi-Pen: ________________ Date of last use: _____ / _____ / ______
In the Event of an Anaphylactic Reaction:
1. Staff/Program Instructors may provide assistance to the Participant as he/she injects him/herself. Note: Staff/Program
Instructors are not trained medical professionals, but have completed the Standard First Aid Training and will assist to the
best of their ability.
2. Staff/Program Instructors will call 9-1-1 immediately to have an ambulance come to the program/event site.
3. Staff/Program Instructors will call parent/legal guardian/emergency contact to inform them of the incident and to inform
them the Participant is being transported by emergency personnel to the hospital.
Epi-Pen Waiver
(Only if Participant requires an Epi-Pen on-site)
I release Lake Havasu City, and its officers, directors, employees, independent contractors, and volunteers from any and all
liability arising out of or in connection with the decision to administer or not administer or to assist with the administration of
epinephrine.
I agree to indemnify and hold harmless Lake Havasu City, and its officers, directors, employees, independent contractors, and
volunteers of and against any and all liability, damage, claim, demand, cost, and expense (including without limitation of
attorney’s fees) arising out of or in connection with the use or non-use of an Epi-Pen for Participant and any action, claim, or
other legal proceeding brought against Lake Havasu City by a parent/legal guardian/spouse/family member who has not signed
in agreement.
Participant/Parent/Legal Guardian Signature:
If Parent or Legal Guardian, Printed Name:
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Medwaiver (Lake Havasu City)

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Completed 14 July 2020

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