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Silver Alert Information Form

Silver Alert Information Form

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Published by Cynthia Caron
Print form in case of need BEFORE a loved one who may wander goes missing. Example: Autism, Dementia, Alzheimer's They may qualify for a Silver Alert. This message by www.lostnmissing.com
Print form in case of need BEFORE a loved one who may wander goes missing. Example: Autism, Dementia, Alzheimer's They may qualify for a Silver Alert. This message by www.lostnmissing.com

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

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08/11/2013

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LostNMissing Inc. , 26 Noyes Road, Londonderry, NH 03053
SILVER ALERT INFORMATION FORM
Keep on hand in case loved one may wander or go missing 
.
Individual’s Identifying Information
Individual with need:
 Name (Last) ___________________ (First) ___________________ M.I ____ Nickname ___________________ Maiden / Other ___________________ 
Address:
Street Address _____________________________________________________________  Apartment/Unit # ___________________ City ___________________ State __________ Zip ____________ Home Phone: ___________________ Alternate Phone ___________________ 
Marital Status:
M S WSpouse’s Name: ____________________________ Does spouse live at same residence? Y/N ____  Address of spouse if different _____________________________________________________________ Spouse’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 __________ Weight __________ Right Eye Color: ___________ Left Eye Color: ________________ Cataracts Y/No __________________ Glasses Y/No ______________ Hair Color: ____________________________ Hair Style: __________________________________________________________ 
(bald, short, cropped, long, ponytail, wig, toupee)
If loved one is already missing, what clothing were they wearing, including shoes? ________________________________  _____________________________________________________________________________  ______________________ 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 Information
 Name of Primary Physician:Specialty of Practice:Address of Physician:Phone of Physician: ____________  Name of Specialty Physician:Specialty of Practice:Address of Physician:Phone of Physician: _____________ 
Vehicle Information
Does individual drive: Y/No?________  Access to car keys? Y/No_________ YEAR _______ MAKE ______________ 

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