Templates Health & Wellness Medical Medical Emergency Contact Form Template

Medical Emergency Contact Form Template

Use This Template
Please enable JavaScript in your browser to complete this form.

Personal Information

Full Name

Emergency Contact

Medical Information

Insurance Information

Consent and Signature

Clear Signature

The Medical Emergency Contact Form Template by WPForms is the best solution for efficiently managing emergency contact information in medical settings.

How Does the Medical Emergency Contact Form Template Work?

Essential for healthcare providers, the form necessitates the WPForms Pro License along with the Signature Addon, ensuring a secure and professional experience for both medical staff and patients. Fields include:

  • Personal Information:
    • Full Name: Records the patient’s name to help with identifying the individual correctly.
    • Date of Birth: Critical for identifying the patient and understanding age-related medical considerations.
    • Gender: Offers context that might be relevant for certain health conditions or treatments.
    • Phone Number: A direct line to the patient for any immediate communication needs.
    • Email Address: Enables electronic correspondence for appointment scheduling and health updates.
  • Emergency Contact: 
    • Emergency Contact Name: Designates a go-to person for any emergencies involving the patient.
    • Relationship to Patient: Clarifies the connection between the emergency contact and the patient.
    • Emergency Contact Email: Provides an alternative communication route to the emergency contact.
    • Emergency Contact Phone: Ensures immediate contact can be made in urgent situations.
  • Medical Information:
    • Physician Name: Identifies the patient’s primary healthcare provider.
    • Physician Email: Facilitates email communication with the patient’s physician.
    • Physician Phone: Allows for direct phone communication with the physician if necessary.
    • Known Allergies: Alerts medical staff to any substances that could cause adverse reactions.
    • Current Medications: Informs healthcare providers of any drugs the patient is taking that could affect treatment.
    • Existing Conditions: Details any ongoing health issues that are crucial for informed medical care.
  • Insurance Information:
    • Insurance Provider: Assists in the administrative processing of medical services.
    • Policy Number: A key identifier for the patient’s health insurance coverage.
    • Group ID: Further details for insurance processing and verification.
    • Policyholder’s Name: Clarifies who holds the insurance policy, which can be different from the patient.
  • Consent and Signature:
    • Agreement Checkbox: Provides legal consent for treatment and data handling for ethical medical practice.
    • Signature and Date: Ensures all information is verified and consented to by the patient or guardian.

Sign up with WPForms today and access the Medical Emergency Contact Form Template. It is perfect for healthcare facilities that want to improve patient information management.