Patient Emergency Contact Information Form

Patient Information

• Full Name: _________________________ Date: //___
• Date of Birth: //___ Age: ___
• Address: _____________________________________________
• Phone: (Home) ____________ (Cell) ____________

Primary Emergency Contact

• Full Name: _________________________________________
• Relationship to Patient: ______________________________
• Address: _________________________________________
• Phone Numbers:
  • Home: ________________
  • Cell: ________________
  • Work: ________________
• Email: ___________________________________________

Secondary Emergency Contact

• Full Name: _________________________________________
• Relationship to Patient: ______________________________
• Address: _________________________________________
• Phone Numbers:
  • Home: ________________
  • Cell: ________________
  • Work: ________________
• Email: ___________________________________________

Healthcare Provider Information

• Primary Care Physician: ______________________________
• Phone: ________________
• Other Specialists: ___________________________________
• Phone: ________________

Medical Information

• Allergies: ________________________________________
• Blood Type (if known): _____
• Current Medications: _______________________________

Authorization

I hereby authorize the release of my medical information to the above-listed emergency contacts in the event of an emergency.

Signature: _________________________ Date: //___

For Office Use Only Received by: _____________ Date: //___ Scanned: □ EMR Updated: □