Emergency Medical Information | Otik Healthcare Services

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Email: info@otikhealth.com
8647 Cherry Lane, Laurel, Maryland, 20707

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Welcome to OTIK Health

Emergency Medical Information

Your safety is our top priority. The Emergency Medical Information section allows us to keep important details about your health on hand in case of an emergency. This ensures that our team has the necessary information—such as allergies, medical conditions, and emergency contacts—to act quickly and appropriately should the need arise. Please provide complete and accurate medical information to help us respond effectively in an emergency situation.

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Individual

Medicaid Number

Date Of Birth

Police / Fire / Rescue 911

Poison Control Center 1-800-552-6337

Whom To Contact In An Emergency

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Name

Address

Relationship

Phone

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Name

Address

Relationship

Phone

Advance Directive

Yes
No

Able to communicate verbally in an emergency?

Yes
No

Any history of substance abuse?

Yes
No

Explain

Current significant medical problems (including asthma, cancer history, cardiac history, hypertension, stroke, seizure, diabetes, sexually transmitted diseases, TB, HIV, hepatitis, other communicable diseases, sensory, ambulatory)

Other information (e.g., walks with a cane, uses wheelchair, other medical needs, communication problems, sensory problems, conditions affecting transportation services, etc.)

ALLERGIES

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Food

Stings/Bites

Drugs

Dietary Restrictions

1. Current Medications (prescribed or over the counter) See also any meds listed on Physician Order Sheet.

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Dose

Time(s)

Reason / other instructions or start date

2. Current Medications (prescribed or over the counter) See also any meds listed on Physician Order Sheet.

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Dose

Time(s)

Reason / other instructions or start date

3. Current Medications (prescribed or over the counter) See also any meds listed on Physician Order Sheet.

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Dose

Time(s)

Reason / other instructions or start date

4. Current Medications (prescribed or over the counter) See also any meds listed on Physician Order Sheet.

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Dose

Time(s)

Reason / other instructions or start date

5. Current Medications (prescribed or over the counter) See also any meds listed on Physician Order Sheet.

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Dose

Time(s)

Reason / other instructions or start date

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1. Medical provider name & speciality

Phone/Fax

Address

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2. Medical provider name & speciality

Phone/Fax

Address

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3. Medical provider name & speciality

Phone/Fax

Address

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4. Medical provider name & speciality

Phone/Fax

Address

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5. Medical provider name & speciality

Phone/Fax

Address

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6. Medical provider name & speciality

Phone/Fax

Address

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Primary Care MD

Pharmacy

Policy Number

Dentist

Health Insurance Company

Group Number

Name of person providing the above information

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Relationship to Individual

Individual

Medicaid Number

Date

Date Of Birth

Employee Name (Original on file in the individual’s’ chart)

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Date received & reviewed

OFFICE USE ONLY

STAFF: At least annually update information above. Also, update list of meds, above, by lining out any discontinued meds and adding new meds.

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Next Update

Employee

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Next Update

Employee

Get in Touch

info@otikhealth.com

(+1) 410-567-1700

Admin Office:

8657 Cherry Ln., Laurel, MD 20707

Day Hub/CDS Day Program Center:

8647 Cherry Ln., Laurel, MD 20707

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