Periodontal Emergency Contact Information Form

Patient Information

• Full Name: ___________________________
• Date of Birth: ________________________
• Address: _____________________________
• Phone: ______________________________
• Email: _______________________________

Emergency Contact Information

• Primary Contact Name: _________________
• Relationship: _________________________
• Phone (Home): ________________________
• Phone (Mobile): _______________________
• Secondary Contact Name: _______________
• Relationship: _________________________
• Phone: ______________________________

Current Medications

• List all medications: __________________
• Anticoagulants: ☐ Yes ☐ No
• Blood thinners: ☐ Yes ☐ No

Medical Alerts

• Allergies: ___________________________
• Previous adverse reactions: ____________

Dental Insurance Information

• Provider: ____________________________
• Policy Number: _______________________
• Group Number: _______________________

Emergency Medical Information

• Primary Care Physician: _______________
• Phone: ______________________________
• Preferred Hospital: ___________________

Authorization

I authorize the release of any medical information necessary to provide emergency care.

Signature: _____________ Date: _________

For Office Use Only Scanned: ☐ | Entered in EMR: ☐ | Staff Initials: ___