Dog or Cat Emergency Medical Profile Example

    This is an example of the Pet information Emergency Personnel, Vet or responsible person can see upon entering your Dog’s Name and Member ID into the ECD online system.
    See an example of the Cat Profile.

     

     

    Dog Information

    • Dog’s Name / Owner’s Name:

      DUKE – Dog / Lynn Smart

       

    • Telephone / Alternate

      +1-555/555-1212 – +1-555/555-1214

       

    • Birth Date

      4/25/2008

       

    • Breed – Blood Type – Gender

      Great Dane – 4 – C – male

       

    • Height – Weight – Coat Color – Eye Color

      2' 10''– 161 lbs. – Black & Grey – Black

       

    • Inoculations

      Canine Distemper    Parvovirus    Hepatitis    Rabies

       

    • Other Treatments

      Leptospirosis    Heartworm    Heatstroke   

       

    • Dog Registration No. / Date

      435-2355    5 31 2008

       

    • Other Registration No. / Date

      Collin County    D253 36472    05 31 08

       

    • Clinic-Hospital / Pet No.

      Pet Health Clinic    D07383

       

    • Microchip Provider / No.

      AnamTec    436427144779129

       

    • Apartment Registration / No.

      Willow Creek Apt.    D5244

       

       

    Medical & Item Alerts

    • Medical Alert Condition:

      Medical Alert
       Please be advised that has Asthma

    • Medicine

      Theophylline

    • Contact / Telephone

      Lynn Smart / +1-555/555-1212

    • Alert Note

      Use with Aerosol Chamber

       

    • Medical Alert Condition:

      Medical Alert
       Please be advised that has Deafness

    • Medicine

      None

    • Contact / Telephone

      Lynn Smart / +1-555/555-1212

    • Alert Note

      Approach from front without quick movements, be calm.

       

    Emergency Contacts

    • Name:

      Jason Lewis

    • Relationship / Contact Type

      Friend    — 1

    • Telephone

      1-777/777-1212

    • Alternate Telephone

      1-777/777-1222

    • Work Telephone

      1-777/777-1224

    • Email

      jason@jhlored.com

    • Address:

      4325 Rosen Lane

    • City/State/Zip/Country

      Eldorado, IL 60657 – USA

       

    Veterinarian Profile

    • Veterinarian Name:

      Richard Durbin, DVM,  – Primary

    • Specialty

      General   Behavior

    • Telephone

      1-777/666-3333

    • Alternate Telephone

      1-777/333-3433

    • Email

      richard@hilored.com

    • Clinic - Hospital Name

      Pet Health Clinic

    • Address:

      6623 Lakeview Plaza

    • City/State/Zip/Country

      Our Town, IL 60609 – USA

       

    Pet Pharmacy Data

    • Pharmacy Name

      CSWalco

    • Telephone

      1-666/665-2332

    • Address:

      4341 San Mateo Drive

    • City/State/Zip/Country

      Out Town, IL 60609

       

    Pet Medicines

    • Medication:

      Avapro  

    • Prescription # / Expiration Date

      432-2345   –   10 / 2014

    • Dosage / Frequency

      300 mg   –   daily

    • Pet Name / Pharmacy Name

      DUKE / CSWalco

    • Notes:

      Treatment for hypertension

       

    Recent Treatments

    • Condition Treated:

      Arthritis  

    • Practitioner / Treatment Date

      Richard Durbin, DVM   –   7 / 12 / 2018

    • Facility Name

      Pet Health Center   –   Arthritic Pain Injection

    • Telephone

      1-555/555-1212

    • Address:

      6630 Lakeview Plaza, Suite 220

    • City/State/Zip/Country

      Our Town, IL 60609 – USA

    • Recent Treatment Notes:

      Spinal disk deterioration

       

    Surgeries & Procedures

    • Surgery:

      Benign skin mass  

    • Surgeon / Surgery Date

      David Brown, DVM   –   5 / 7 / 2018

    • Facility Name

      Pet Health Center   –   Out-patient

    • Telephone

      1-555/666-1212

    • Address:

      6630 Lakeview Plaza, Suite 220

    • City/State/Zip/Country

      Our Town, IL 60609 – USA

    • Notes:

      Lab work came back negative. Return yearly for checkup.

       

    Allergies

    • Allergy Statement

      0 I have no known drug allergies.

    • Food Allergy Notes:

      Peanuts

       

    • Asthma / Hay Fever Allergies:

      Asthma

    • Environment Allergies:

      Stings and Insect Bites

    •  

    Health Insurance

    • Insurance Company

      PetAssurance   –   Primary Health Plan

    • Plan Name

      Pets First

    • Subscriber Number / Group Number

      46832 3342 2232   /   A6256

    • Policy Members

      Duke Smart, Tabitha Smart

    • Insurance Card Number / Card Date

      5327234523-2   –   4 / 5 / 2016

    • Payer ID Number / Effective Date

      4722 3421   –   4 / 4 / 2016

    • COPAY – O Visit / Spec OV / Urg Care / ER

      10 / 25 / 40 / 40

    • RX COPAY – Tier 1 / Tiew 2 / Tier 3

      20 / 55 / 80

    • Consumer Telephone

      +1 - 888 / 555 - 1212

    • Provider Telephone

      +1 - 888 / 555 - 1214

    • Health Insurance Notes:

      Call for all non-emergency treatments

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