Special Medical Needs Information form
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Special Medical Needs Form
Brunswick County Emergency Services has developed a computerized registry of people with special medical needs who may require special assistance in the event of a disaster such as a tornado, severe storm, or chemical spill. Please fill out the form below and when you click submit, all information will be automatically placed in our database.
* Last Name 
* First Name 
Date of Birth 
Language
* Street Address
* City
* State
* Zip Code
Mailing Address
City
State
Zip Code
* Phone Number 
Primary Caregiver
Caregiver Phone
Primary Physician Name
Physician Phone
Pharmacy
Pharmacy Phone
* Indicates Response Required


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