Cardiac Surgery Patient Emergency Contact Information Form

Patient Information

• Full Name: ________________________________
• Date of Birth: //________
• Medical Record #: _________________________
• Primary Phone: (_) -

Primary Emergency Contact

• Full Name: ________________________________
• Relationship to Patient: ____________________
• Primary Phone: (_) -
• Secondary Phone: (_) -
• Email: ___________________________________
• Address: _________________________________

Secondary Emergency Contact

• Full Name: ________________________________
• Relationship to Patient: ____________________
• Primary Phone: (_) -
• Secondary Phone: (_) -
• Email: ___________________________________

Healthcare Proxy Information

• Do you have a Healthcare Proxy? □ Yes □ No
• If Yes, Name: _____________________________
• Phone: (_) -

Additional Information

• Preferred Language: _______________________
• Need for Interpreter: □ Yes □ No
• Special Instructions: ______________________

Authorization

I confirm that the information provided above is accurate and authorize the cardiac surgery team to contact the listed individuals in case of emergency.

Signature: _________________________________ Date: //________

For Office Use Only Form Received By: __________________________ Date Entered: //________ Verified By: _______________________________