Occupational Therapy Patient Emergency Contact Form

Patient Information

• Full Name: ___________________________
• Date of Birth: ________________________
• Address: _____________________________
• Phone (Home): ________________________
• Phone (Mobile): ______________________
• Email: ______________________________

Primary Emergency Contact

• Full Name: ___________________________
• Relationship to Patient: ________________
• Phone (Primary): ______________________
• Phone (Alternative): ___________________
• Address: _____________________________

Secondary Emergency Contact

• Full Name: ___________________________
• Relationship to Patient: ________________
• Phone (Primary): ______________________
• Phone (Alternative): ___________________
• Address: _____________________________

Medical Information

• Primary Care Physician: ________________
• Phone: ______________________________
• Known Allergies: ______________________
• Current Medications: __________________
• Medical Conditions: ___________________

Authorization

I authorize the occupational therapy practice to contact the above individuals in case of emergency. I confirm that all provided information is accurate and current.

Signature: _____________________________ Date: ________________________________

For Office Use Only

• Form Received By: ____________________
• Date Processed: ______________________
• Updated in System: □ Yes □ No
• Notes: ______________________________