Speech Therapy Patient Emergency Contact Information Form

Patient Information

• Full Name: ________________________________
• Date of Birth: //______
• Address: __________________________________
• Phone: (__) -

Primary Emergency Contact

• Full Name: ________________________________
• Relationship to Patient: _____________________
• Phone (Home): (__) -
• Phone (Cell): (__) -
• Phone (Work): (__) -
• Address: __________________________________

Secondary Emergency Contact

• Full Name: ________________________________
• Relationship to Patient: _____________________
• Phone (Home): (__) -
• Phone (Cell): (__) -
• Phone (Work): (__) -
• Address: __________________________________

Medical Information

• Primary Care Physician: _____________________
• Phone: (__) -
• Known Allergies: ___________________________
• Current Medications: _______________________
• Medical Conditions: ________________________

Release Authorization

I authorize the speech therapy practice to contact the above individuals in case of emergency. I also authorize the release of relevant medical information to emergency contacts and medical personnel if needed.

Signature: ___________________ Date: //___

For Office Use Only

• Form Received By: ___________________________
• Date Processed: //______
• Updated in System: □ Yes □ No