Internal Medicine Emergency Contact Information Form

Patient Information

• Full Name: ______________________________
• Date of Birth: //___
• Medical Record Number: ________________
• Home Address: _________________________
• Phone: (__) -

Primary Emergency Contact

• Name: ________________________________
• Relationship to Patient: _________________
• Phone (Primary): (__) -
• Phone (Alternative): (__) -
• Email: ________________________________

Secondary Emergency Contact

• Name: ________________________________
• Relationship to Patient: _________________
• Phone (Primary): (__) -
• Phone (Alternative): (__) -
• Email: ________________________________

Critical Medical Information

• Primary Insurance: _____________________
• Policy Number: ________________________
• Blood Type (if known): _________________
• Allergies: ____________________________
• Current Medications: ___________________

Primary Care Physician

• Name: ________________________________
• Practice: _____________________________
• Phone: (__) -

Authorization

I authorize the release of this information to medical personnel in the event of an emergency.

Signature: _____________________________ Date: //___

Please update this form annually or when information changes