VALLEY ELECTRIC
MEMBERSHIP CORPORATION, INC.
 318-352-3601

_____________________________________________________________________________

Priority Medical List: 

Please complete this form to identify members with special needs as requested by their physician so they can be placed on a priority list in case of an emergency.  

DATE ____________________________               

PATIENT __________________________               MEDICAL CONDITION 

ADDRESS _________________________                _________________________ 

             __________________________               _________________________ 

             __________________________               _________________________ 

             __________________________               _________________________ 

PHONE   __________________________               DOCTOR SIGNATURE

VEMCO ACCOUNT #_________________               _________________________ 

RETURN TO:        VEMCO
                         P.O. BOX 659
                         NATCHITOCHES, LA  71457 

                         FAX# 318-352-8570