The e-Cig Emporium Inc.

Emergency Contact Information Form

Your Name: ____________________________________________________________

Last First MI

Phone: (___)________________

Address: _______________________________________________________________
Street City State

Emergency Contact Name:_______________________________________________

Last First

Work Phone: (___)________________ Home Phone: (___)_____________

If unavailable (2nd) Contact Name: _________________________________________

Last First

Work Phone: (___)________________ Home Phone: (___)_____________

Preferred local hospital: ___________________________________________________

Insurance Information:

Company: __________________________________ Policy #: ___________________

Comments (include any special medical or personal information you would want an
emergency care provider to know – or special contact information: