If this is an emergency, please call 911!

Justin Case (19 Years Old)

EpiPen is located in the left side pocket of school bag (red with initials JIC). Justin has a hard time breathing and breaks out in hives when he is having an alergic reaction. Please use the EpiPen ASAP in case of emergency and call 911!

Allergies

  • Latex
  • Peanuts
  • Soy
  • Dairy

Medical Devices

  • Contact Lenses

Medical Problems

  • Situs Inversus

Surgery

  • Tonsillectomy

Latest Tetanus Shot

  • March 2011

Additional Key Information: 

EpiPen is located in the left side pocket of school bag (red with initials JIC). Justin has a hard time breathing and breaks out in hives when he is having an alergic reaction. Please use the EpiPen ASAP in case of emergency and call 911!

If this is an emergency, please call 911!

Justin Case

Photo

Justin Case

Age: 19 Years Old
DOB: Feb 13, 2000
Speaks: English

Primary Contact

Primary Medical Care Provider

Additional Contacts
1

Medications
4

Medication Name Dose Strength Frequency Route Notes
Teen Multivitamin (Brand A) One Pill listed online Daily Oral view company website for ingredients and amounts
Allergy-B-Gone Daytime (chemical name here) 10mg N/A PRN (as needed) Oral primarily spring and fall
Zit-Away (generic chemical name here) one application 0.05% once nightly Topical
Anti-Cooties Shot 0.5 mL 50mg/mL Monthy Injection In arm
  • Teen Multivitamin (Brand A)
    Dose
    One Pill
    Strength
    listed online
    Frequency
    Daily
    Route
    Oral
    Info
    view company website for ingredients and amounts
  • Allergy-B-Gone Daytime (chemical name here)
    Dose
    10mg
    Strength
    N/A
    Frequency
    PRN (as needed)
    Route
    Oral
    Info
    primarily spring and fall
  • Zit-Away (generic chemical name here)
    Dose
    one application
    Strength
    0.05%
    Frequency
    once nightly
    Route
    Topical
    Info
  • Anti-Cooties Shot
    Dose
    0.5 mL
    Strength
    50mg/mL
    Frequency
    Monthy
    Route
    Injection
    Info
    In arm

Additional Medical Care Providers
4

Physicians Name Phone Beeper Specialty
Dr. Dewey Hafta (999) 999-9999 Family Medicine
Dr. Clem E. Hans (999) 999-9999 Allergist
Dr. Havah Koff (999) 999-9999 Otolaryngology (ENT)
Dr. Guttman (999) 999-9999 Internist
  • Dr. Dewey Hafta
    Phone
    (999) 999-9999
    Pager
    Specialty
    Family Medicine
  • Dr. Clem E. Hans
    Phone
    (999) 999-9999
    Pager
    Specialty
    Allergist
  • Dr. Havah Koff
    Phone
    (999) 999-9999
    Pager
    Specialty
    Otolaryngology (ENT)
  • Dr. Guttman
    Phone
    (999) 999-9999
    Pager
    Specialty
    Internist

Pharmacies
1

Name Phone Fax Address City/Province, State ZIP/Postal
Local Chain Pharmacy (999) 999-9999 (999) 999-9990 123 Next Block Over Hometown, PA 19066
  • Local Chain Pharmacy
    Phone
    (999) 999-9999
    Fax
    (999) 999-9990
    Address
    123 Next Block Over
    Hometown, PA 19066

Location of Electronic Health Records

Justin's doctors are at CHOP-Children's Hospital of PA. His records are all stored there.

Location of Legal Documents
1

Document Contact Name Relationship Phone Fax Address City/Province, State ZIP/Postal
Medical Power of Attorney Mom E Case Mother 610-555-5555 111 Mom East Parentville, PA 19094
  • Medical Power of Attorney
    Contact Name
    Mom E Case
    Relationship
    Mother
    Phone
    610-555-5555
    Fax
    Address
    111 Mom East
    Parentville, PA 19094

Preferred Care Center
1

  • Emergency Room
    CHOP
    4th street and Civic Center Boulevard
    Philadelphia, PA 19104