Endocrinology Patient Emergency Contact Form

Patient Information

• Full Name: ___________________________
• Date of Birth: ________________________
• Medical Record #: ______________________
• Primary Phone: ________________________
• Address: _____________________________

Medical Information

• Primary Endocrine Condition(s):

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  • ---

• Current Medications:

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  • ---

• Allergies: ____________________________
• Insulin Dependent: □ Yes □ No
• Insulin Type(s): _______________________

Primary Emergency Contact

• Name: _______________________________
• Relationship: _________________________
• Phone (Home): ________________________
• Phone (Mobile): _______________________
• Address: _____________________________

Secondary Emergency Contact

• Name: _______________________________
• Relationship: _________________________
• Phone (Home): ________________________
• Phone (Mobile): _______________________

Healthcare Providers

• Primary Care Physician: ________________
  • Phone: _____________________________
• Endocrinologist: ______________________
  • Phone: _____________________________

Emergency Instructions

• Preferred Hospital: ____________________
• Special Medical Instructions:

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Authorization

I authorize the above contacts to be notified and make medical decisions in case of emergency:

Signature: _____________ Date: __________