Medical Emergency Form
Name of Trust
Name & Surname
First Name
Last Name
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is the nature of your emergency
Do you need to see/go to
Doctor
ER
Hospital
Please specify which Dr/ER/Hospital
Do you need transport
Yes
No
Do you need an ambulance
Yes
No
Please note Trustees cannot provide any medical advice
Always call your doctor first
24h medical emergencies call: 060 885 1574
Upload quote/statement/invoice or receipt here
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