HealthONE - July 16, 2018

Knowing exactly what paperwork you need to leave for a caregiver is very important. Do you know what you need to leave with them? If not, then you are not alone. Please read on to learn what every caregiver should have. In your absence, and in an emergency, you will want your child/children to get the best medical care possible. This can help bring you peace of mind so that you will be more at ease while you are away. Below are things you need to have on your Caregiver ER Checklist.
Note: This checklist is a general guide. More or different information may be needed to address specific healthcare situations.

Personal information

  1. Your child’s/childrens' legal full name(s), date of birth(s), weight(s), height(s)
  2. Your full home address, city, state, and zip code. Provide cross streets (in case a call needs to be made to 911 or other emergency responders)

Medical information

  • Medical conditions (from childbirth on, including any hospital stays, including to the NICU as an infant)
  • All Allergies
  • Medication name(s), dosage and frequency taken
  • Insurance cards

Physician information

  • Pediatrician’s full name, address, phone number(s), and office hours
  • Dentist’s full name, address, phone number(s), and office hours
  • Address of the nearest ER where you’d want your child/children to be taken (with directions, too)

 Important Contact Information:

  1. All phone numbers to reach you. If you are out of town, please include the name and number of your accommodations, and anyone else at your location who can contact you
  2. Phone numbers of your closest trusted relatives
  3. Phone numbers of your nearest reliable neighbor(s) (who agreed in advance to help if needed), and their addresses. You might want to have contact information for an additional in-town person as backup.
  4. Poison control center number


Treatment Permission Form
This form will allow healthcare professionals the permission needed to provide medical treatment for your child/children while they are in someone else's care (whether it's a babysitter, relative such as a grandparent, etc.). If a child is legally considered a minor in your state, the ER must regard the child as such. Requirements for authorizations to treat a minor vary by state and/or medical facilities, so you should check to make sure you know what is required in your area.