Nursing Home Emergency Contact Form
Please complete this form with accurate information. This form will be used in case of an emergency involving the resident.
Resident Information
Resident Name: | |
Room Number: | |
Emergency Contact Information
Primary Contact |
Name: | |
Relationship to Resident: | |
Phone Number: | |
Alternate Phone Number: | |
Email Address: | |
Secondary Contact (if applicable) |
Name: | |
Relationship to Resident: | |
Phone Number: | |
Alternate Phone Number: | |
Email Address: | |
Physician Information
Physician Name: | |
Phone Number: | |
Medical Information
Health Insurance Information |
Insurance Provider: | |
Policy Number: | |
Group Number: | |
Allergies (if any): | |
Medications (please list all current medications with dosages) |
Medication 1 |
Dosage: | |
Medication 2 |
Dosage: | |
Additional Information/Instructions
I, [Your Name], understand that the information provided on this form is accurate to the best of my knowledge and authorize [Your Company Name] to use this information in case of an emergency involving the resident.
[Month, Day, Year]
Please return this form to the front desk upon completion. Thank you for your cooperation.
Nursing Home Templates @ Template.net
