Medical Needs Registry


Medical Needs Registry Form

 
Please be as complete as possible in your responses.

* = Required Fields

First Name:*
Middle Initial:
Last Name:*
Street Address:*
   Number:   Street Name:    Type: 
   Line 2:
   City:   State:    Zip: 
Mailing Address: (if different from street address)
   Number:   Street Name:    Type: 
   Line 2:
   City:   State:    Zip: 
Residence Type:*
    If Other, specify type:
    Name of Subdivision:
Phone Numbers:
    Primary:* - - Extn:  TTY: - -
    Secondary/Cell: - - Extn:  TTY: - -
E-mail:
Date of Birth:* (mm/dd/yyyy)
Gender:*
Do you have a Service Animal?*
If Yes, specify approx weight:* lbs
Number of Household Pets:
    Dog(s):
    Cat(s):
    Other types of pets (include a quantity):
Do you have or can you arrange your own transportation?*
Do you currently use public transportation (Fastran, MetroAccess, bus, rail, taxi)?*
If Fastran, specify your ID number:
Do you require an ambulance for transportation?*
Can you sit in a regular car/bus/van seat?*
Do you need a wheelchair lift/ramp?*
Can you independently transfer to/from a wheelchair?*
Are you confined to a bed?*
Can you climb stairs?*
Do you regularly receive assistance from a caregiver?*
If Yes, provide caregiver's First Name:    
  Middle Initial:
  Last Name:
  Phone Number: - - Extn:
  Secondary/Cell Number: - -
  TTY: - -
  E-mail:
Will a caregiver/companion accompany you to the shelter?*
If Yes, provide caregiver/companion's First Name:    
  Middle Initial:
  Last Name:
  Phone Number: - - Extn:
  Secondary/Cell Number: - -
  TTY: - -
  E-mail:
Emergency Contact:*
Please provide emergency contact's First Name:    
  Middle Initial:
  Last Name:
  Phone Number: - - Extn:
  Secondary/Cell Number: - -
  TTY: - -
  E-mail:
What is the name of your home health care agency?
What is the name of your medical equipment supplier(s)?
Supplier 1:
Supplier 2:
Supplier 3:
Do you plan to evacuate to a public shelter if required?*
Is your medical condition temporary?*
If temporary, give expected medical release date (mm/dd/yyyy):
Check all that apply to your condition:






Other acute conditions: (please specify)
Are you dependent on any of the following: (Check all that apply)


Other Medical Equipment: (please specify)
Mobility: (Check all that apply)

Do you require assistance with: (Check all that apply)

Name of your primary physician:*
First Name:
  Middle Initial:
  Last Name:
  Phone Number: - - Extn:
 
Who should be contacted for verification of information on this registration form?*

If Other, please specify relationship:
 
Who is filling out this registration form? (Relationship to registrant)*


If Other, please specify relationship:
If not Self, provide First Name:    
  Middle Initial:
  Last Name:
  Phone Number: - - Extn:
  Secondary/Cell Number: - -
 
By submitting my information,
 
  • I agree that it may be shared with other Fairfax County agencies and their partner agencies and organizations.
  • In addition, I give local law enforcement personnel and responders permission to enter my home in case of an emergency.