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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
Use this template

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

How to use the Emergency Contact Form

Getting started with this template takes just a few minutes. Sign up for a free Formisoft trial, then select the Emergency Contact Form from the template library. The form is ready to use immediately, but you can customize every field, add your practice logo, and adjust the layout to match your workflow.

Setup steps

  1. 1Choose the template. Find the Emergency Contact Form in the template library and click “Use this template” to add it to your account.
  2. 2Customize fields. Add, remove, or reorder any of the 11 fields. Set fields as required or optional based on your practice needs.
  3. 3Brand it. Upload your logo, pick your colors, and add a custom welcome message so patients see your practice identity.
  4. 4Share with patients. Send the form via SMS, email, or embed it on your website. Patients complete it on any device before their visit.
  5. 5Review submissions. Responses appear in your dashboard in real time. Patient records are created automatically from the data collected.

Frequently asked questions

Is the Emergency Contact Form HIPAA compliant?

Yes. All Formisoft templates, including the Emergency Contact Form, are HIPAA compliant. Data is encrypted with 256-bit AES at rest and TLS 1.3 in transit. A Business Associate Agreement (BAA) is included on every plan.

Can I customize the fields in this template?

Absolutely. You can add, remove, reorder, or modify any of the 11 fields. You can also add conditional logic, new pages, file uploads, e-signatures, and payment fields.

How do patients fill out this form?

Patients receive a link via SMS, email, or QR code. They complete the form on their phone, tablet, or computer before their appointment. No app download required.

Can I send this form automatically before appointments?

Yes. Formisoft's workflow automation can send intake forms automatically when an appointment is booked. You can set the timing (e.g., 48 hours before the visit) and include reminders for patients who haven't completed it.

Does this template work on mobile devices?

Yes. The Emergency Contact Form is fully responsive and works on any device. Most patients complete intake forms on their phone, so every template is optimized for mobile-first use.

8 min saved per patient98% patient satisfaction3x faster than paper

Start with this template

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