Medical Condition And Equipment Form

If you have a medical condition that requires you to use medical equipment that relies on electricity, please print this form and have it signed by your doctor.  This will notify us that there are people living in your home who need restoration sooner.  We will make every effort to respond to your needs. However, we can not guarantee that we will restore electricity in a manner that would not threaten your dependence on medical equipment or would accommodate your medical condition. Section 1 is for Haywood EMC account information and Section 2 must be completed by your physician and returned to our office.