Child: _________________ Date: _________________
When to call: Unconscious, seizures, severe low blood sugar, can't wake up
Phone: 911
Name: _________________
Phone: _________________
After Hours: _________________
Name: _________________
Phone: _________________
Office Hours: _________________
Name: _________________
Phone: _________________
Extension: _________________
Primary Contact: _________________
Phone: _________________
Work Phone: _________________
Secondary Contact: _________________
Phone: _________________
Insurance: _________________
Policy Number: _________________
Pharmacy: _________________
Phone: _________________
Name: _________________
Address: _________________
Phone: _________________
Name: _________________
Address: _________________
Phone: _________________
24-Hour: _________________
Low Blood Sugar: Give 15g fast-acting sugar, recheck in 15 minutes
Severe Low: Give glucagon, call 911
High Blood Sugar: Check ketones, contact doctor if >300