Physical Therapy Patient Emergency Contact Form

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Address: _________________________________________________
• Phone (Home): _____________ (Cell): _____________ (Work): _____________
• Email: _________________________________________________

Primary Emergency Contact

• Full Name: _________________________ Relationship: _____________
• Address: _________________________________________________
• Phone (Primary): _____________ (Alternative): _____________
• Email: _________________________________________________

Secondary Emergency Contact

• Full Name: _________________________ Relationship: _____________
• Phone (Primary): _____________ (Alternative): _____________

Medical Information

• Primary Care Physician: _________________ Phone: _____________
• Preferred Hospital: ________________________________________
• Insurance Provider: _________________ Policy #: _____________
• Known Allergies: _________________________________________
• Current Medications: _____________________________________

Medical Consent

I authorize [Practice Name] to provide emergency medical care and to contact the above-listed individuals in case of emergency. I understand that this information will be kept confidential and only used in emergency situations.

Signature: _________________________ Date: //___

For Office Use Only

• Form Received By: _________________ Date: //___
• Entered in EMR: □ Yes □ No
• Scanned to Patient File: □ Yes □ No

Please notify the clinic of any changes to this information