Colorectal Surgery Patient Emergency Contact Information Form

Patient Information

• Full Name: ____________________________
• Date of Birth: //____
• Medical Record Number: ________________
• Primary Phone: ()-_____
• Secondary 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 designated Healthcare Proxy? □ Yes □ No
• If yes, Name: _________________________
• Phone: ()-_____

Medical Alert Information

• Allergies: ____________________________
• Blood Type (if known): _________________
• Current Medications: __________________

Preferred Hospital

• Name: _______________________________
• Address: ____________________________

Authorization

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

Signature: _______________ Date: //____

Please notify the office of any changes to this information.