Dermatology Patient Emergency Contact Information Form

Patient Information

• Full Name: ______________________________
• Date of Birth: //______
• Medical Record Number: ________________

Primary Emergency Contact

• Full Name: ______________________________
• Relationship to Patient: _________________
• Primary Phone: (__) -
• Secondary Phone: (__) -
• Email: ________________________________
• Address: ______________________________
  • City: _____________ State: ___ ZIP: _____

Secondary Emergency Contact

• Full Name: ______________________________
• Relationship to Patient: _________________
• Primary Phone: (__) -
• Secondary Phone: (__) -
• Email: ________________________________

Medical Information

• Primary Care Physician: __________________
• PCP Phone Number: (__) -
• Preferred Hospital: _____________________
• Known Allergies: _______________________
• Current Medications: ____________________

Authorization

I authorize the release of medical information to the emergency contacts listed above in the event of a medical emergency.

Signature: _________________ Date: //______

For Office Use Only Date Received: //______ Processed By: ______________ Scanned: □ Yes □ No