Urgent Care Patient Emergency Contact Form

Patient Information

Full Name: _________________________________ Date: //___ Date of Birth: //___ Age: ____ Gender: □ M □ F □ Other Social Security Number: --____ Address: ________________________________________________ City: _________________ State: _____ ZIP: ________ Phone: (__) - Email: _______________________

Primary Emergency Contact

Full Name: _________________________________________________ Relationship to Patient: ______________________________________ Phone (Primary): () - Phone (Alternative): () - Address: ________________________________________________

Secondary Emergency Contact

Full Name: _________________________________________________ Relationship to Patient: ______________________________________ Phone (Primary): () - Phone (Alternative): () -

Medical Information

Primary Care Physician: _____________________________________ Phone: (__) - Known Allergies: __________________________________________ Current Medications: _______________________________________ Preferred Hospital: ________________________________________

Insurance Information

Primary Insurance: ________________________________________ Policy Number: ___________________________________________ Group Number: ___________________________________________

Consent

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

Patient/Guardian Signature: ___________________ Date: //___

For Office Use Only

Form Received By: _________________ Date: //___ Scanned to EMR: □ Yes □ No Initial: _____