CHECK INTO ER

Full Name

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Phone Number

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Injury

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Upload Image of Injury (if applicable)

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Rate your Pain (1 being low, 10 being high) Rate Pain 1 2 3 4 5 6 7 8 9 10

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Is this an emergency? Emergency? Yes No

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Are you a child, adult, pregnant or elderly? Personel? Child Adult Pregnant Elderly

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Does you condition require you to lay down or be in a wheel chair? Condition? Lay Down Wheel Chair Neither

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Is there a lot of blood loss? Blood Loss? Yes No

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Have you been admitted to the ER or received surgical treatment within the past month? Admitted? Yes No