Special Needs Form

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ORLAND FIRE PROTECTION DISTRICT
9788 W 151 ST
ORLAND PARK, IL 60462

Business Phone 708-349-0074

Emergency Medical Information

The Orland Fire District maintains a confidential list of RESIDENTS with medical conditions who live within the Fire District. We use this information only in an emergency to provide better care.

If you or a family member has a medical problem that the Orland Fire District should know about, you can submit the information to us on this form. Please provide all information requested. When you are done, scroll down and click "Submit Form." All information will be kept confidential for emergency use only.

* REQUIRED FIELD

Patient Information *
Patient Name
Street Address	Apt / Unit Number
City (Select one)	Orland Park Orland Hills
State	Illinois
Zip Code
Phone
Email
Special Needs (Check all that apply)
Hearing Impaired Visually Impaired Speech Impaired Paraplegic Mentally Disabled Wheel Chair / Confined to Bed Bedroom Location (list floor, location) Allergies To what?
Please include any other useful information.
Patient's Doctor Information
Doctor Name
Doctor Phone
Person(s) to contact in case of emergency *
Emergency Contact 1
Relationship
Contact Phone
2nd Phone

Emergency Contact 2
Relationship
Contact Phone
2nd Phone

Validation Question *	What color are OFPD engines?

Keep a current list of medications on the side of the refrigerator for paramedics.