Cardiology Patient Emergency Contact Information Form

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Medical Record #: __________________ SSN (last 4): __________

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: (____) -____

Cardiac-Specific Information

• Cardiologist Name: _________________
• Practice Phone: (____) -____
• Device Information (if applicable):
  • Pacemaker Model: ________________
  • ICD Model: _____________________
  • Device Clinic: __________________

Current Medications

Allergies

Preferred Hospital

• Name: ____________________________
• Address: __________________________

Authorization

I authorize the release of this information to emergency medical personnel:

Signature: _____________ Date: //___