Patient Information
- Full Name: _________________________ Date of Birth: //____
- Medical Record Number: ______________ Social Security #: --___
- Home Address: ________________________________________________
- Primary Phone: _________________ Secondary Phone: _________________
- Email: _______________________________________________________
Primary Emergency Contact
- Full Name: __________________________________________________
- Relationship to Patient: ________________________________________
- Home Phone: _________________ Mobile Phone: ___________________
- Work Phone: _________________
- Address: ____________________________________________________
Secondary Emergency Contact
- Full Name: __________________________________________________
- Relationship to Patient: ________________________________________
- Home Phone: _________________ Mobile Phone: ___________________
- Work Phone: _________________
- Address: ____________________________________________________
Healthcare Proxy Information
- Do you have a Healthcare Proxy? □ Yes □ No
- If yes, Name: ________________________________________________
- Phone: _________________ Relationship: _________________________
Medical Information
- Primary Care Physician: _______________________________________
- Phone: _________________
- Other Specialists: ____________________________________________
- Preferred Hospital: ___________________________________________
- Insurance Provider: __________________________________________
- Policy Number: ______________________________________________
Allergies and Current Medications
- Known Allergies: ____________________________________________
- Current Medications: ________________________________________
Authorization
I authorize the release of this information to emergency medical personnel in the event of a medical emergency.
Signature: _________________________ Date: //____
For Office Use Only
Form Received By: __________________ Date: //____
Scanned to EMR: □ Yes □ No