Emergency Contacts.

When Traveling Abroad...

When traveling abroad it is extremely important that you carry a list of people who can be reached in an emergency. Fill out the fields in the form below and then print it. If you would like you can submit your information to Genesee Infectious Diseases and Travel Medicine, we will keep your information in a database and should we recieve a call regarding your need for emergency information we can refer them to your listed numbers. When you print this document the individual fields will print blank. You will need to maually fill in these fields and keep a copy fo this document with you whenever you travel.

Your Personal Information:

* denotes a required field

First Name: *

Last Name: *

Blood Type: *

Address: *

City: *

State: *

Zip: *

Home Phone: *	Work Phone: *
E-mail: *	ICQ#:

List Any Special Medical Conditions or Allergies:

Contact 1

Relation: *

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Home Phone: *	Work Phone: *
E-mail:	ICQ#:

Contact 2

Relation: *

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Home Phone: *	Work Phone: *
E-mail:	ICQ#:

Contact 3

Relation: *

First Name: *

Last Name: *

Address: *

City: *

State: *

Zip: *

Home Phone: *	Work Phone: *
E-mail:	ICQ#:

NOTICE: The person carrying this emergency contact list would like you to contact the people listed for consultation on necessary medical treatment or emergency aid. In the event that you cannot reach one of these individuals, please contact the following:

Office hours are Monday through Friday:
9:00 a.m. until 12:00 noon and 2:00 p.m. until 5:00 p.m.
We accept cash, check, Visa and Mastercard.

C. Michael Lewis, D.O.
G-8195 S. South Saginaw Street
Suite B
Grand Blanc, MI 48439

Phone: (810) 694-5393
Toll Free: 800-966-5393
Fax: (810) 694-5394

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