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Issue and Record Emergency Medication You Dispense

Use this screen to record emergency medication you dispense to patients from closed clinics

Instructionsadd

Once a new patient has consented to this database search you can use this screen to locate emergency records for a patient that has been forced to move from their home clinic during a disaster.

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If possible, please use identifying information from officially issued government ID, such as a Driver’s License, State ID or Passport to complete each field below.

All red fields are required and must be completed. You cannot enter any characters, spaces, or numbers into a name field. You must enter numbers into the date of birth and SSN fields. Follow the instructions on each line, and the system will prompt you if you try to submit incorrect items into a particular field. Once you submit your inquiry, the system will compare your entry to the Central Registry database.

During an emergency, a patient may not provide complete information. You must follow your individual clinic procedures in order to verify the information that follows your search request.

Select State and Site

Input Patient's Information

Use the patient's legal first name, you may include a space and/or the characters – and ‘

Use the patient's legal last name, you may include a space and/or the characters – and ‘

If the patient doesn't have an SSN, enter four zeros (0000)

The date must be entered as MM-DD-YYYY

Patient's Gender