Pediatric and emergency medicine groups created this form so a child with special health care needs gets prompt, appropriate care on arriving at an emergency department or other setting with an acute illness or injury, when neither a parent nor the child's pediatrician is available. It concisely summarizes diagnoses, baseline findings, medications, allergies and emergency management for physicians, parents, EMS professionals and nurses.
The child's primary care physician or specialist completes the whole form with the parent and signs it.
Download the current version from the source each time; forms change without notice.
Emergency Information Form for Children With Special Health Care Needs
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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The child's primary care physician or specialist, working with the parent, completes and signs it. ACEP and the AAP describe it as a tool for physicians, parents, EMS professionals and nurses to transfer critical information when the parent or the child's pediatrician cannot be reached during an emergency.
The posted PDF is a scanned image without fillable fields, but ACEP also offers a blank interactive Word version that can be completed electronically, and a sample completed EIF that shows the expected level of detail. No Spanish version is listed on ACEP's page.