1003-smith-margaret sample 2

Emergency Medical Profile

Margaret Jane Ann Smith

Printed on product as “"Maggie"”

Life-Saving Alerts — Critical May resist being touched or guided. Do not raise your voice. Mentioning her husband's name "Arthur" or talking about "gardening" instantly calms her anxiety. Check left wrist for an active GPS tracking bracelet

Vital Medical Alerts

Primary Medical Condition Alzheimer/dementia
Communication & Mobility Needs Lives with husband. Tends to wander toward the local community park if the front door is left unlatched. Verbal but frequently disoriented to time and place. May become non-verbal or repeat phrases when highly stressed. Uses a cane for short distances.

Emergency Contacts

Primary Emergency Contact

Arthur Smith

husband/caregiver

(574) 297-6703
Backup Emergency Contact

Susan Miller

daughter

(555) 444-5566
Additional Emergency Contact

Memory Care Support Line

Case Manager Cathy

(555) 777-8899

Patient Demographics

Date of Birth 11/12/1944
Home Address 742 Evergreen Terrace
Anytown, IN 46923

Medications & Dosage

  • Donepezil (Aricept) —

    10mg — nightly

  • Memantine (Namenda)

    10mg — twice daily

  • Lisinopril (Blood Pressure)

    10mg — daily

Clinical & Insurance Details

Primary Care Physician Dr. Robert Evans, Geriatric Specialist (555) 999-0011
Insurance Provider & Policy # (optional) Blue Cross Policy number :123456789 Group # J258/

Legal Authorization

I authorize emergency medical personnel and first responders to access the information on this profile for the purpose of providing emergency medical care to the individual named above. This information is accurate to the best of my knowledge as of the date listed below.

Form Completed By Susan Miller Daughter
Date Completed 06-08-2026

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