Chiropractic Patient Emergency Contact Form

Patient Information

Full Name: _____________________________ Date: _______________ Date of Birth: _____________ Gender: □ M □ F □ Other Address: ________________________________________________ City: _________________ State: _______ ZIP: ________________ Phone (Home): ______________ (Mobile): ____________________ Email: _________________________________________________

Primary Emergency Contact

Name: _________________________________________________ Relationship to Patient: ____________________________________ Phone (Primary): ________________ (Alt.): ___________________ Address: ________________________________________________ City: _________________ State: _______ ZIP: ________________

Secondary Emergency Contact

Name: _________________________________________________ Relationship to Patient: ____________________________________ Phone (Primary): ________________ (Alt.): ___________________ Address: ________________________________________________ City: _________________ State: _______ ZIP: ________________

Medical Information

Primary Care Physician: ____________________________________ Phone: _________________________________________________ Known Allergies: _________________________________________ Current Medications: ______________________________________

Authorization

I authorize the above contacts to be notified and receive information about my condition in case of emergency.

Signature: _______________________ Date: __________________

For Office Use Only: Received by: __________________ Date: ____________________ Entered in EMR: □ Yes □ No