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Emergency Contact Form
Registration

Emergency Contact Form

2 pages•11 fields•HIPAA-ready
Ready to useHIPAA compliantCustomize in minutes
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Emergency Contact Form

Emergency Contact Form

Page 1 of 2

Patient Full Name
Jane Martinez
Date of Birth
03/15/1985
Primary Emergency Contact Name
Contact person
Relationship to Patient
Select relationship...
Primary Contact Phone
(555) 867-5309
Primary Contact Email
jane.martinez@email.com
Secondary Emergency Contact Name
Contact person
Secondary Contact Phone
(555) 867-5309
Authorized for Medical Decisions
Option A
Option B
Option C
Authorized to Receive Health Info
Option A
Option B
Option C
Patient Signature
Sign here
Submit
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Sign up and start customizing in minutes.

The Emergency Contact Form ensures your practice has up-to-date contact information for the people patients want notified in case of a medical emergency. It captures primary and secondary emergency contacts with their relationship to the patient, multiple phone numbers, and availability preferences. Having this information readily accessible is critical for patient safety and timely communication.

Beyond basic contact details, this form identifies individuals authorized to make medical decisions on the patient's behalf and those permitted to receive protected health information. Patients can specify different contacts for different purposes, such as one person for emergencies and another for billing inquiries. This granular approach respects patient autonomy while ensuring compliance with HIPAA authorization requirements.

Used across all healthcare settings including hospitals, outpatient clinics, surgical centers, and long-term care facilities. This form is especially important for elderly patients, pediatric practices where multiple guardians may be involved, and surgical facilities where next-of-kin notification is a regulatory requirement.

What's included

  • Primary and secondary emergency contact details
  • Relationship and availability information
  • Medical decision-making authorization
  • HIPAA-compliant information release authorization
  • Multiple phone number fields per contact
  • Patient signature and date of completion

Who uses this template

  • New patient registration in any healthcare setting
  • Surgical pre-admission and pre-operative intake
  • Pediatric practices requiring multiple guardian contacts
  • Long-term care and assisted living facility admissions

All form fields

11 fields across 2 pages. Customize any field after signing up.

Patient Full NameText
Date of BirthDate
Primary Emergency Contact NameEmergency Contact
Relationship to PatientDropdown
Primary Contact PhonePhone
Primary Contact EmailEmail
Secondary Emergency Contact NameEmergency Contact
Secondary Contact PhonePhone
Authorized for Medical DecisionsMultiple Choice
Authorized to Receive Health InfoMultiple Choice
Patient SignatureE-Signature
8 min saved per patient98% patient satisfaction3x faster than paper

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