Vascular Surgery Patient Emergency Contact Information Form

Patient Information

• Full Name: ________________________________
• Date of Birth: //______
• Medical Record #: __________________________
• Primary Phone: (____) -
• Secondary Phone: (____) -

Primary Emergency Contact

• Full Name: ________________________________
• Relationship to Patient: ____________________
• Primary Phone: (____) -
• Secondary Phone: (____) -
• Address: __________________________________
• City/State/ZIP: ____________________________

Secondary Emergency Contact

• Full Name: ________________________________
• Relationship to Patient: ____________________
• Primary Phone: (____) -
• Secondary Phone: (____) -
• Address: __________________________________
• City/State/ZIP: ____________________________

Healthcare Proxy Information

• Do you have a Healthcare Proxy? □ Yes □ No
• If yes, Name: _____________________________
• Phone: (____) -

Additional Information

• Preferred Language: ________________________
• Need for Interpreter: □ Yes □ No
• Preferred Hospital: ________________________

Authorization

I confirm that the information provided above is accurate and current. I authorize the vascular surgery team to contact the individuals listed above in case of emergency.

Signature: _________________________________ Date: //______

For Office Use Only Date Received: //______ Processed By: ______________________________ Scanned to EMR: □ Yes □ No