Vial of Life

Please note that all information filled out on this form is NEVER SEEN or SAVED

If you have not already obtained a vial to place the form in please go to Mesquite Fire and Rescue (3 John Deere Drive) or Smith’s Pharmacy (350 N Sandhill blvd) and get the vial with the needed sticker for free.

1. Fill out the form as completely as possible.  Remember that all fields are optional.  Please fill out a new form any time your medications change.  New forms can be obtained at Mesquite Fire and Rescue, Smiths Pharmacy, or online by clicking the link below.
2. Place completed form in the vial and place the vial anywhere inside your refrigerator (in the door of the refrigerator is preferred). You may also consider putting a copy of a DNR (Do Not Resuscitate) or Living will inside the vial as well.
3. Place the provided sticker on your front door to let first responders know where you medication list can be found.