Nutrition Services Emergency Contact Form

Patient Information

Full Name: _________________________________ Date: //___ Date of Birth: //___ Age: _____ Gender: _____

Address: ________________________________________________ City: _________________ State: _____ ZIP: _________

Phone: (Home) _____________ (Cell) _____________ (Work) _____________ Email: _________________________________________________

Emergency Contact Information

Primary Contact

Name: ________________________________________________ Relationship to Patient: ____________________________________ Phone: (Home) _____________ (Cell) _____________ (Work) _____________

Secondary Contact

Name: ________________________________________________ Relationship to Patient: ____________________________________ Phone: (Home) _____________ (Cell) _____________ (Work) _____________

Medical Information

Primary Care Physician: ____________________________________ Phone: _________________

Allergies (food/medication): _________________________________

Current Medications: ______________________________________

Medical Conditions (check all that apply):

□ Diabetes □ Heart Disease □ Hypertension □ Food Allergies □ Eating Disorder □ Other: _______________

Authorization

I authorize the release of this information in case of emergency:

Signature: _________________________ Date: //___

Print Name: _________________________