Patient Information
- Full Name: _________________________ Date of Birth: //___
- Address: ________________________________________________
- Phone: (Home) _____________ (Cell) _____________ (Work) _____________
- Email: _________________________________________________
Primary Emergency Contact
- Name: ________________________________________________
- Relationship to Patient: ___________________________________
- Phone: (Home) _____________ (Cell) _____________ (Work) _____________
- Address: ________________________________________________
Secondary Emergency Contact
- Name: ________________________________________________
- Relationship to Patient: ___________________________________
- Phone: (Home) _____________ (Cell) _____________ (Work) _____________
- Address: ________________________________________________
Medical Information
Current Medical Conditions
Allergies
- Medications: ____________________________________________
- Other: ________________________________________________
Current Medications
- Name: __________________ Dosage: ________ Frequency: ________
- Name: __________________ Dosage: ________ Frequency: ________
- Name: __________________ Dosage: ________ Frequency: ________
Primary Insurance Information
- Insurance Provider: _______________________________________
- Policy Number: _________________________________________
- Group Number: _________________________________________
Authorization
I authorize the release of this information to emergency medical personnel in the event of an emergency.
Signature: _________________________ Date: //___
For Office Use Only
Form Received By: __________________ Date: //___
Scanned to EMR: □ Yes □ No