MEDICAL EQUIPMENT INFORMATION | South Central Electric Association

MEDICAL EQUIPMENT INFORMATION

YES - Please add me/us tothe Life Support / Medical Equipment List.

Please remove:

Please remove:
	Please remove:	Item weight

more items

from the Life Support / Medical Equipment List.

First

Middle

Last

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number:

Type of life-support equipment or medical condition:

Backup Power

Battery backup available?

Yes

If yes, approximately how long will the batteries last?

Generator available on site?

Yes

Signature:

Sign above

Date: