Dental Emergency Contact Form

Patient Information

• Full Name: ________________________
• Date of Birth: //____
• Address: ________________________
• Phone: (__) -
• Email: ________________________

Primary Emergency Contact

• Name: ________________________
• Relationship to Patient: ________________________
• Phone (Home): (__) -
• Phone (Mobile): (__) -
• Address: ________________________

Secondary Emergency Contact

• Name: ________________________
• Relationship to Patient: ________________________
• Phone (Home): (__) -
• Phone (Mobile): (__) -
• Address: ________________________

Medical Information

• Primary Care Physician: ________________________
• Phone: (__) -
• Known Allergies: ________________________
• Current Medications: ________________________

Insurance Information

• Dental Insurance Provider: ________________________
• Policy Number: ________________________
• Group Number: ________________________

Authorization

I authorize the dental practice to contact the above individuals in case of emergency. I confirm that all information provided is accurate and current.

Signature: ________________________ Date: //____

Please notify the office immediately if any of the above information changes.