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Firestone Police Department Voluntary Consent Form - Medical Information

  1. Purpose of This Program
    To help the Firestone Police Department be better prepared in responses, individuals can utilize this form to self report health concerns or issues within a home. Examples can include medical background information (dementia, hospice care, etc.), mental health concerns, child custody issues and more. This reporting form is a way for individuals to disclose information to the police about their conditions so that when police are faced with challenging situations they have a better understanding of the situation at hand.

    By completing this form the signer is authorizing the release of protected health information to law enforcement agencies and other emergency responders.
  2. This information will be entered into a Law Enforcement Data System to help responding agencies assist persons with a qualifying illness or condition to obtain medical, mental health and social services when responding to a request for an emergency service. The information will be accessed only to provide necessary information to responding law enforcement officers and other emergency personnel to assist in an emergency situation.
  3. Please Check One: *
  4. Gender:
  6. Provide symptoms, activities or other information that would be helpful for a responding officer to be aware of for the safety of this person and others. Please provide as much information as possible.
  7. Contact Information:
    Required to have a minimum of two listed. This information will be provided to emergency personnel if the above person is contacted and in need of assistance. Fill out as many as possible.
  8. Check Here
  9. For more information, please contact the Firestone Police Department by calling 303-833-0811.

  10. Leave This Blank:

  11. This field is not part of the form submission.