Pender County Special Needs Registry Application For Shelter and Evacuation

Last Name *

First Name *

Middle Name *

Patient Phone Number *

Physical Address *

City *

Zip *

State *

Mailing Address if Different

Caregiver's Name *

Caregivers Phone Number *

Emergency Contact's Name *

Emergency Contact Phone Number *

Relationship *

Emergency Contact Address *

Your Primary Care Physician *

Physician's Telephone *

Home Health Provider *

Primary Language *

Do you use oxygen? *YesNo

How Often Do You Use Your Oxygen? (optional) *(___ Hours per Day at ___ Rate Liters/Min)

What Type of Oxygen Do You Have? (optional)

ConcentratorPortable Tank

Amount of oxygen you have on hand? (optional)

What Type of Medications Do You Take? (optional)

OralSubcutaneous Injections (SQ)Intramuscular Injections (IM)Intravenous (IV)

How Mobile Are You? (optional)

Bed BoundWheelchair BoundWalk with Assistance (walker, cane, another person)Walk Independently

Do You Have Any of the Following Devices? (optional)

Urinary CatheterOstomyPacemakerImplanted Pump/Catheter/Tube

What Kind of Vehicle Can You Ride In?

Car/BusWheelchair Accessible VehicleAmbulance Only

Are You Mentally Handicapped? *YesNo

Do You Have a Service Animal? *YesNo

Please List Any Additional Information You Think Necessary To Your Care Below: (optional)0 / 180

What Type of Oxygen Do You Have? (optional)

What Type of Medications Do You Take? (optional)

How Mobile Are You? (optional)

Do You Use Any Special Medical Device? (optional)

Are you... (optional)

Do You Have Any of the Following Devices? (optional)

What Kind of Vehicle Can You Ride In?

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