Oral Surgery Emergency Contact Form

Patient Information

• Full Name: ________________________
• Date of Birth: //______
• Address: _________________________
• Phone: (__) -
• Email: __________________________

Primary Emergency Contact

• Full Name: ________________________
• Relationship to Patient: ____________
• Home Phone: (__) -
• Cell Phone: (__) -
• Work Phone: (__) -
• Address: _________________________

Secondary Emergency Contact

• Full Name: ________________________
• Relationship to Patient: ____________
• Home Phone: (__) -
• Cell Phone: (__) -
• Work Phone: (__) -
• Address: _________________________

Medical Information

• Primary Care Physician: ____________
• PCP Phone: (__) -
• Known Allergies: __________________
• Current Medications: ______________
• Medical Conditions: _______________

Authorization

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

Signature: ________________________ Date: //______

For Office Use Only Form Received By: _________________ Date Entered: //______ Scanned: □ Yes □ No