General Surgery Patient Emergency Contact Information Form

Patient Information

Date: //_____

Primary Information

• Full Name: _________________________ Date of Birth: //____
• Medical Record Number: _____________
• Social Security Number: _____________

Contact Information

• Home Address: ________________________________________________
• City: _________________ State: _______ ZIP: __________
• Primary Phone: (__) - □ Mobile □ Home □ Work
• Secondary Phone: (__) - □ Mobile □ Home □ Work
• Email: ________________________________________________

Emergency Contacts

Primary Emergency Contact

• Full Name: ________________________________________________
• Relationship to Patient: ______________________________________
• Primary Phone: (__) - □ Mobile □ Home □ Work
• Secondary Phone: (__) - □ Mobile □ Home □ Work
• Address: ________________________________________________

Secondary Emergency Contact

• Full Name: ________________________________________________
• Relationship to Patient: ______________________________________
• Primary Phone: (__) - □ Mobile □ Home □ Work
• Secondary Phone: (__) - □ Mobile □ Home □ Work
• Address: ________________________________________________

Healthcare Proxy Information (if applicable)

• Full Name: ________________________________________________
• Phone: (__) -
• Relationship to Patient: ______________________________________

Authorization

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

Patient/Guardian Signature: ___________________ Date: //____

For Office Use Only Verified By: _________________ Date: //____ Scanned to EMR: □ Yes □ No