Emergency Contact Information
Patient Name
*
First Name
Last Name
Date of Birth
*
Email
*
example@example.com
Client ID
Emergency Contact #1
If you would like either of your Emergency Contacts to have access to your personal medical information please complete a separate Release of Information for each individual.
Emergency Contact Name
*
First Name
Last Name
Relationship to Patient
*
Phone Number #1
*
-
Area Code
Phone Number
Phone Number #2
-
Area Code
Phone Number
Information that can be released:
Pathology/Diagnostic/Procedure test results:
*
Yes
No
ER Report:
*
Yes
No
Financial/Billing information:
*
Yes
No
Appointment Dates/Times:
*
Yes
No
May pick up Medications:
*
Yes
No
Immunization Records:
*
Yes
No
Would you like any information specifically excluded?
Emergency Contact #2
If you would like either of your Emergency Contacts to have access to your personal medical information please complete a separate Release of Information for each individual.
Emergency Contact Name
First Name
Last Name
Relationship to Patient
Phone Number #1
-
Area Code
Phone Number
Phone Number #2
-
Area Code
Phone Number
Information that can be released:
Pathology/Diagnostic/Procedure test results:
Yes
No
ER Report:
Yes
No
Financial/Billing information:
Yes
No
Appointment Dates/Times:
Yes
No
May pick up Medications:
Yes
No
Immunization Records:
Yes
No
Would you like any information specifically excluded?
Emergency Contact #3
If you would like either of your Emergency Contacts to have access to your personal medical information please complete a separate Release of Information for each individual.
Emergency Contact Name
First Name
Last Name
Relationship to Patient
Phone Number #1
-
Area Code
Phone Number
Phone Number #2
-
Area Code
Phone Number
Information that can be released:
Pathology/Diagnostic/Procedure test results:
Yes
No
ER Report:
Yes
No
Financial/Billing information:
Yes
No
Appointment Dates/Times:
Yes
No
May pick up Medications:
Yes
No
Immunization Records:
Yes
No
Would you like any information specifically excluded?
Signature
*
Clear
Date
*
-
Month
-
Day
Year
Date
Please verify that you are human
*
Submit
Patient ID _____________
Should be Empty: