formisoft

Emergency Contact Form

Asks about primary emergency contact name, relationship to patient, and primary contact phone. Built for new patient registration in any healthcare setting.

Questions
11
Pages
2
Time
about 3 min

Includes

  • E-signature
  • Emergency contact
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Your practice

Emergency Contact Form

Page 1 of 2 · Your information

Emergency Contact

Live preview. Tap through it like a patient.

Who it is for

  • 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

Formisoft for Pediatrics

What's inside

Page 1 · Your information

  1. Patient Full NameText · Required
  2. Date of BirthDate
  3. Primary Emergency Contact NameEmergency Contact
  4. Relationship to PatientDropdown · 5 choices
  5. Primary Contact PhonePhone

Page 2 · Additional details

  1. Secondary Emergency Contact NameEmergency Contact
  2. Secondary Contact PhonePhone
  3. Authorized for Medical DecisionsMultiple Choice · 3 choices
  4. Authorized to Receive Health InfoMultiple Choice · 3 choices
  5. Patient SignatureE-Signature

From form to a ready patient

  1. The Formisoft form builder with editable questions and required toggles

    01

    Make it yours

    Reword, reorder, or add to the Emergency Contact Form, and add your logo.

  2. A patient filling out a Formisoft form on a phone

    02

    Patients finish it at home

    A secure link by text or email, filled out on their phone before the visit. No app.

  3. The Formisoft dashboard showing how many of today's patients are ready

    03

    Your team sees who is ready

    Each visit shows as ready once its forms are in. Answers land on the patient record.

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Questions

Responses are encrypted, only your team can see them, and a BAA is included.

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

Yes. Attach the form to a visit type and every patient who books gets it right away, with a reminder before the visit if it is not done. Your calendar shows which visits are ready.

Send it before the visit, so patients arrive ready.

Book a short call and we will set up the Emergency Contact Form for your practice, ready to send before the next visit.

BAA included · We set up your front desk

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