Staff / Medical and Emergency

MEDICAL AND EMERGENCY INFORMATION

* Indicates required field

Member Name *

First

Last

Emergency Name (Primary) *

First

Last

Relation (P) *

Phone Number (P) *

Emergency Name (Secondary) *

First

Last

Relation (S) *

Phone Number (S) *

Physician *

Physician’s Phone *

Medical/Hospital Insurance Company *

Policy Holder’s Name *

Group Number *

Policy / ID Number *

Allergies *

Medical Conditions *

Drug Allergies *

Medications *

Food Allergies *

Have you received the COVID vaccination? *

Yes No

Acceptable proof of vaccination includes:

The CDC COVID-19 Vaccination Card issued to the vaccine recipient by the vaccination site, or an electronic or physical copy of the same;
Official record from the New Jersey Immunization Information System (NJIIS) or other State immunization registry;
A record from a health care provider’s portal/medical record system on official letterhead signed by a licensed physician, nurse practitioner, physician’s assistant, registered nurse or pharmacist;
A military immunization or health record from the United States Armed Forces; or
Docket mobile phone application record or any state specific application that produces a digital health record.

Upload Proof Of Vaccination Card *

Max file size: 20MB

Vaccine against COVID-19 is readily available at multiple pharmacies. To find a COVID-19 vaccination clinic near you: Visit the NJ COVID-19 Vaccine Appointment Finder: https://covid19.nj.gov/pages/finder or call NJ Vaccine Call Center at 855-568-0545.

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