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Silver Alert Information Form

Silver Alert Information Form

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Published by Cynthia Caron

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Published by: Cynthia Caron on Aug 03, 2013
Copyright:Attribution Non-commercial


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LostNMissing Inc. , 26 Noyes Road, Londonderry, NH 03053
Keep on hand in case loved one may wander or go missing 
Individual’s Identifying Information
Individual with need:
 Name (Last) (First) M.INickname Maiden / Other 
Street Address Apartment/Unit #City State ZipHome Phone: Alternate Phone
Marital Status:
M S WSpouse’s Name: Does spouse live at same residence? Y/N __  Address of spouse if differentSpouse’s Phone: Spouse’s Cell No:
Caregiver Info
Name (Last) (First) M.I.Relationship to individual:Street Address Apartment/Unit #City State Zip
Information on Individual:
DOB: Gender: Height WeightRight Eye Color: Left Eye Color:Cataracts Y/No Glasses Y/NoHair Color:Hair Style:
(bald, short, cropped, long, ponytail, wig, toupee)
Race/Nationality (check all that apply. If bi-racial, check both categories)Is the Individual bi-racial? Y/No ____  ____American Indian or Alaska Native ____Asian ____Caucasian ____Black or African American ____Hispanic or Latino ____Native Hawaiian or Other Pacific Islander ____ Middle EasternMedical Conditions:Medications (with dosage)1. 2. 3.4. 5. 6.Emotional Status (well, agitated, hallucinations, anxiety, etc.)_________________________ Does Individual have psychological disorders? Y/No____ Type of Disorders, if any: ____________________________________________ Is Individual at risk of Self Harm? Y/No_________ Under care of Psychiatrist? Y/No _________ Hearing Impairment Y/No _____ Vision impairment Y/No_______ Allergies Y/No?________ List of Allergies __________________________________ Walks unassisted Y/No_________ Uses Cane ________ Other: _________________________ Identifying Marks:
Healthcare InformationVehicle Information
 Name of Specialty Physician:Specialty of Practice:Address of Physician:Phone of Physician: Name of Primary Physician:Specialty of Practice:Address of Physician:Phone of Physician:
Does individual drive: Y/No?________  Access to car keys? Y/No_________ YEAR _______ MAKE ______________ MODEL________________ COLOR _________________ Name of State on License Plate _______________ Plate Number (Tag) ______________________ 

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