Prefer it online? Patients fill it out on their phone before the visit.
Practice name: ______________________________
Emergency Contact Form
Your information
Patient Full Name *
Date of Birth
____ / ____ / ________
Primary Emergency Contact Name
Name
Relationship
Phone
Relationship to Patient
- Self
- Parent
- Legal guardian
- Spouse or partner
- Other
Primary Contact Phone
Primary Contact Email
Additional details
Secondary Emergency Contact Name
Name
Relationship
Phone
Secondary Contact Phone
Authorized for Medical Decisions
- Yes
- No
- Not sure
Authorized to Receive Health Info
- Yes
- No
- Not sure
Patient Signature
Date
Emergency Contact Form template from formisoft.com. formisoft.com/intake-templates/emergency-contact