Patient Information
- Full Name: _________________________ Date of Birth: //___
- Medical Record #: ___________________ SSN: --____
- Address: ________________________________________________
- Phone: (Home) _____________ (Cell) _____________ (Work) _____________
Primary Emergency Contact
- Name: ________________________________________________
- Relationship to Patient: ___________________________________
- Phone Numbers:
- Primary: ________________
- Secondary: ______________
- Address: ________________________________________________
- Email: _________________________________________________
Secondary Emergency Contact
- Name: ________________________________________________
- Relationship to Patient: ___________________________________
- Phone Numbers:
- Primary: ________________
- Secondary: ______________
Current Medications
- List all medications, including supplements:
-
-
-
Medical Alerts
- Allergies: _____________________________________________
- Implanted Devices: ____________________________________
- Blood Type: __________
Healthcare Proxy Information
- Name: ________________________________________________
- Phone: _______________________________________________
- Relationship: _________________________________________
Preferred Hospital
- Name: ________________________________________________
- Address: ______________________________________________
Authorization
I hereby authorize the release of my 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