Why the Lifeline Program Matters

In a medical emergency, first responders need accurate information right away: your medications, allergies, medical conditions, emergency contacts and more. The Lifeline form is designed to be completed in advance and placed on your refrigerator so it can be found quickly.

Please print clearly, keep this form up to date, and place it in the Lifeline pocket on your refrigerator with the Lifeline sticker on your front door. This simple step can help ensure your wishes are followed and may help save your life.

Lifeline Information Form

Personal Information
Medical Conditions & Allergies

Check all that apply.

Past Medical Conditions & Last Hospitalization

Please describe your last hospitalization (why, where, when, etc.) and list any important past medical conditions.

Current Medications

Example: Lasix 20 mg – 1 tablet 2x daily.

Special Instructions

Example: DNR, location of Living Will, religious or personal directions, etc.

Emergency Contacts

Tip: After filling out this form in your browser, click “Print / Save as PDF” and choose “Save as PDF” in your print dialog if you would like to keep a digital copy before printing it for your refrigerator.

Nearby Hospitals & Medical Centers

  • Holy Name Medical Center – (201) 833-3000
  • The Valley Hospital – (201) 447-8000
  • Englewood Hospital – (201) 894-3000
  • Hackensack Meridian HUMC – 551-996-2000
  • HUMC Pascack Valley – (201) 383-1035
In an emergency, always dial 911 first. Then follow local instructions from emergency personnel.