VANCE,HENRY SAMPLE

Emergency Medical Profile

Henry Thomas Vance

Printed on product as “Henry”

DOB:11 / 04 / 1959

Primary Medical Condition Severe Coronary Artery Disease & Bradycardia
Life-Saving Alerts — Critical HEART PATIENT. PACEMAKER IMPLANTED. TAKES BLOOD THINNERS
Medical Devices & Implants Medtronic Dual-Chamber Pacemaker (Implanted 2024). Port-a-cath in upper right chest.

Vital Medical Alerts

Communication & Mobility Needs None. Mentally alert, but may become extremely short of breath or fatigued under physical stress.
Special Instructions for First Responders High bleeding risk due to blood thinners. Monitor pacemaker function. Do not place large magnets near left chest.
Dependents or Pets at Home — Wellness Check Needed One indoor cat (Bella) at home alone.

Emergency Contacts

Primary Emergency Contact

Martha Vance

Spouse

(574) 297-6703Tap to call
Backup Emergency Contact

David Vance

Son

(555) 017-3311Tap to call
Additional Emergency Contact

Dr. Susan Vance (No Relation)

Cardiologist (St. Vincent Heart Care)

(555) 012-8800Tap to call

Patient Demographics

Home Address 1422 Old Orchard Lane
Delphi, IN 46923

Medications & Dosage

  • Apixaban (Eliquis)

    5mg — 2x Daily

  • Lisinopril

    10mg — 1x Daily (Morning)

  • Metoprolol Succinate

    25mg — 1x Daily (Night)

Clinical & Insurance Details

Primary Care Physician Dr. Keith Larson
(555) 012-7744Tap to call
Insurance Provider & Policy # (optional) Medicare Part B / Policy: #MED-422-91-83A

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 Martha Vance (Spouse)
Date Completed 06 / 16 / 2026

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