support@carehausagency.com
(508) 320-4985
P.O.Box 654 Upton MA 01568
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Home
About
Services
Personal Care Assistance
Homemaking Support
Companion Care
Transportation
Blogs
Careers
Forms
Service Areas
Contact
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Emergency / Disaster Plan
PATIENT NAME:
PCP Name:
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ADDRESS:
ADDRESS:
CITY/ZIP:
CITY/ZIP:
PHONE:
Phone:
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Emergency Contacts
Emergency Contact 1:
*
Emergency Contact 2:
Relationship:
*
Relationship:
Phone:
*
Phone:
IN THE EVENT OF A HURRICANE OR OTHER NATURAL DISASTER, I PLAN TO TAKE THE FOLLOWING ACTION:
REMAIN IN THE HOME
GO TO A LOCAL SHELTER
GO TO A SPECIAL CARE UNIT
EVACUATE TO A SAFE AREA
CARE UNIT:
ARE YOU REGISTERED?
Yes
No
DO YOU NEED HELP IN REGISTERING?
Yes
No
GO TO RELATIVES / OTHER LOCATION:
Location:
Address:
Contact Person:
Phone Number:
Classifications:
a. client depends on electric equipment for life support
b. client is med dependent for life support and/or ongoing iv
c. client is wheelchair or bed bound, needs assist to evacuate
d. clients that are frail, live alone – and/or—medically fragile clients not previously classified
e. all other clients
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