Emergency Contact Form Template

Emergency Contact

Name of Person Covered:

Date of Birth:

Current Address:

Primary Phone Number:

Primary Emergency Contact

First Name *

Last Name *

Email Address *

Primary Phone Number *

Secondary Phone Number:

Relationship to Covered Person

Address (if different from Covered Person)

Authority to Make Decisions

Yes, authorized to act as surrogate/proxy.

No, only authorized to receive information.

Secondary Emergency Contact

First Name

Last Name

Relationship to Covered Person

Primary Phone Number

Secondary Phone Number

Email Address

Medical Information (For Emergencies)

Primary Care Physician (PCP): Name

Primary Care Physician (PCP): Phone

Known Allergies: (Specify medications, food, environment, etc.)

Current Medications: (List names and dosages or state etc")

Pre-Existing Medical Conditions: (e.g., Diabetes, Hypertension, Epilepsy, Asthma)

Health Insurance Provider Name:

Health Insurance Provider Policy/Group ID:

Authorization and Special Instructions

Treatment Consent (Required in some settings):

Nearest Emergency Facility Preference: (Name of preferred hospital or clinic)

In the event that immediate treatment is required and the covered person or authorized contact cannot be reached, do you authorize emergency medical personnel to administer necessary care?

Yes

Other Critical Notes: (e.g., "Hearing impaired," "Has a pacemaker," "Must be accompanied by service animal")

Legal/Formal Contacts

Legal Guardian/Power of Attorney (POA) Name:

POA Phone Number:

Signature & Date

Signature of Covered Person / Parent / Guardian:

Use your mouse or finger to sign in the box below.

Date Signed:

Date Last Updated:

(CID : 18022)

New Patient Enrollment

New Patient Enrollment