Orthodontic Emergency Contact Information Form

Patient Information

Full Name: ___________________________ Date of Birth: //___ Address: ___________________________________________________ Phone: (Home) _____________ (Cell) _____________ (Work) _____________

Primary Emergency Contact

Name: ____________________________________________________ Relationship to Patient: ______________________________________ Phone: (Home) _____________ (Cell) _____________ (Work) _____________

Secondary Emergency Contact

Name: ____________________________________________________ Relationship to Patient: ______________________________________ Phone: (Home) _____________ (Cell) _____________ (Work) _____________

Medical Information

Primary Care Physician: ______________________________________ Phone: ___________________________________________________ Allergies: ________________________________________________ Current Medications: ________________________________________

Orthodontic Appliance Information

Type of Appliance: □ Traditional Braces □ Clear Aligners □ Retainer □ Other Date of Installation: //___

Emergency Authorization

I hereby authorize [Practice Name] to provide emergency orthodontic treatment for the above-named patient in my absence. I understand that every effort will be made to contact me or the designated emergency contacts before initiating treatment.

Signature: _________________________ Date: //___ Print Name: ________________________ Relationship: ____________

Office Use Only

Chart #: _____________ Date Received: //___ Staff Initial: ___________