Bastrop County EMS

Yellow Dot Enrollment

What is Yellow Dot? Bastrop County ESD 3 offers Yellow Dot free of charge to residents with complex medical conditions. After you fill out this form a community health paramedic will call or email to confirm the information. Once confirmed you will receive two decals and two folders already filled out with your details. One decal goes on your rear window; the other goes by your front door where responders can spot it easily. These decals tell responders your medical history, allergies, medicine, and emergency contacts are inside an envelope in your glovebox or magnetized to your fridge.

This information helps first responders act quickly in an emergency. Fields marked (optional) can be left blank. Everything else should be filled in if it applies to you. Questions? Call 512-409-7700 or email [email protected].

Personal Information

Last Name

First Name

Middle Name (optional)

Date of Birth

2x2 Photo
(optional)

Upload a recent photo or take a photo of client (optional)

Demographic Information

Street Address

City

State

ZIP Code

Phone Number

Email (optional)

Preferred Contact Method

Call Email Text

How should a community health paramedic reach you to confirm this enrollment?

Insurance Information (optional)

Medicare #

Medicaid #

Insurance Name

Insurance ID

Insurance Group

Medical History

Asthma

Arthritis

Heart Disease

Lung Disease

Diabetes

High Blood Pressure

Neurologic Condition

Autism

Developmental Delay

Other

Allergies

List any known allergies (write "none" if none)

Current Medications (optional)

Medication	Dosage	Frequency	I take this for...	Prescriber

Advanced Directive Do you have a DNR (Do Not Resuscitate) order?

Yes No

If yes, please have a copy of your DNR available with your Yellow Dot materials for easy access by responders.

Emergency Contact #1

Last Name

First Name

Relationship

Phone Number

Emergency Contact #2 (optional)

Last Name

First Name

Relationship

Phone Number

This form generates a filled PDF entirely in your browser. No data leaves your device until you choose to email it. If you prefer to enroll by phone, call 512-409-7700.

Bastrop County EMS

Your enrollment form is ready

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