Pleasefillindetailsclearlyin CAPITAL LETTERS andtick () allrelevantboxes

Personal information / Your medication and allergies
If you have a
photograph of
yourself, please
put it here.
Date completed
/ First name ______
Surname ______

Male Female


Date of birth

Blood group
(if known) / Do you have any of the following conditions?
(Please tick ALL boxes that apply.)

EpilepsyAsthmaOther


DiabetesHeart Please give details

Do you have any allergies?

______


Are you on the NHS Organ Donor Register? Yes No

Do you have any other medical conditions we should be aware of?

What you need to do …..

1. / If more than one member of the household is included,
please complete one form for each person and make
sure that all forms are kept inside one bottle only.
Further bottles are available from:
Age UKSouth Gloucestershire
67 High Street
Thornbury,
BS35 2AW Telephone: 01454 411707 / 1.
2.
3.
4.
5. / Complete the details above and overleaf. You can get
medical information from your GP or Health Visitor.
Place the completed form inside the plastic bottle.
Put the container in the fridge door.
Put one of the stickers on the outside of the fridge.
Don’t cover it!
Put the other sticker on the kitchen door on the side
facing the hallway.

Your Doctor’s Details

/
Emergency Contacts
Name:______
Telephone: ______
GP. Address:______

Please give details of your next of kin

Name ______

Address______

______
Post Code ______Telephone ______
Relationship to you ______/ Please give the details of two people who can be contacted
in case of emergency. If possible they should live close to you.
Name:Name:
______
AddressAddress
______
______
______
Post Code ______Post Code______Telephone ______Telephone______

Message in a Bottle

This voluntary emergency information scheme provides Essential and Emergency Services Staff with vital details of any illness or allergy and someone to contact should they be called to your home as a result of a sudden illnessor a personal accident.

  • For use by anyone who feels vulnerable while living at home.
  • Provides emergency rescue services with vital details of any illness or allergy.
  • Provides emergency services with a contact name if they are called to your home

This project is operatedin partnership with South Gloucestershire Council

Registered charity number 1109999

Revised-Sept 2011