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 Office of the
Eaton County Sheriff

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Sheriff Tom Reich

1025 Independence Blvd
Charlotte, Michigan 48813

517-543-3512 or 517-372-8217

 

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Request for Special Medical Attention Form

EATON COUNTY 9-1-1 EMERGENCY MEDICAL INFORMATION

 

NAME: ____________________________________________________   DATE: _________________________

 

ADDRESS: __________________________________________________________________________________

 

CITY: ________________________ STATE: _________ ZIP: _______________ PHONE: _______________

 

RACE: _____ SEX: _____ DATE OF BIRTH: ____________ HEIGHT: _______ WEIGHT:   _____________

 

HAIR COLOR: _________ EYE COLOR: _________   SOCIAL SECURITY: ___________________________

 

DRIVER’S LICENSE: __________________________________________________ STATE: _______________

 

VEHICLES: __________________________________________________________________________________

 

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IMPORTANT MEDICAL INFORMATION/NEEDS: _________________________________________________

 

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EMERGENCY CONTACT:

 

NAME: ____________________________________________________ HOME PHONE:____________

 

ADDRESS: _______________________________________         WORK PHONE: ______________

 

CELL PHONE OR PAGER: (specify)_______________________________________________________

 

 

NAME: ___________________________________________       HOME PHONE:_______________

 

ADDRESS: ________________________________________        WORK PHONE: ______________

 

CELL PHONE OR PAGER: (specify)_______________________________________________________

 

Requested by:   ______________________________   Agency: __________________________________

 

Return to:

Bob Robison, Supervisor

Eaton County Central Dispatch

911 Courthouse Dr.

Charlotte, MI 48813

517-543-4948

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Click to download the Autism Emergency Contact Form Click to download Request for Special Medical Attention Form

 


Either of these forms can be mailed to us at 1025 Independence Blvd, Charlotte, MI 48813, Faxed to 517-543-2922

or emailed to treich@eatoncounty.org and they will be put on file with Central Dispatch  

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