Emergency Contact List-Confidential and Proprietary

 

Assisted Living Company Name:

Resident Information

  1. Resident Name: __________________________________________________

  2. Room Number: ________________________ Date of Birth: _____________

  3. Primary Phone Number: ___________________________________________

  4. Primary Physician Name: __________________________________________
    Phone: ________________________ Address: _________________________

Primary Emergency Contact

  1. Name: _________________________________________________________

  2. Relationship to Resident: _________________________________________

  3. Phone Number (Home): ________________ (Mobile): _________________

  4. Email Address: __________________________________________________

  5. Address: _______________________________________________________

  6. Preferred Method of Contact: ☐ Phone ☐ Email ☐ Text ☐ Other: _______

Secondary Emergency Contact

  1. Name: _________________________________________________________

  2. Relationship to Resident: _________________________________________

  3. Phone Number (Home): ________________ (Mobile): _________________

  4. Email Address: __________________________________________________

  5. Address: _______________________________________________________

  6. Preferred Method of Contact: ☐ Phone ☐ Email ☐ Text ☐ Other: _______

Tertiary Emergency Contact

  1. Name: _________________________________________________________

  2. Relationship to Resident: _________________________________________

  3. Phone Number (Home): ________________ (Mobile): _________________

  4. Email Address: __________________________________________________

  5. Address: _______________________________________________________

  6. Preferred Method of Contact: ☐ Phone ☐ Email ☐ Text ☐ Other: _______

Additional Contacts

  1. Power of Attorney (POA) Name: ____________________________________
    Phone: ________________________ Email: __________________________
    Address: _______________________________________________________

  2. Guardian/Conservator Name (if applicable): _________________________
    Phone: ________________________ Email: __________________________
    Address: _______________________________________________________

  3. Other Important Contacts:

    • Name: ________________________ Relationship: ____________________
      Phone: ________________________ Email: _________________________

    • Name: ________________________ Relationship: ____________________
      Phone: ________________________ Email: _________________________

Special Instructions

  1. Preferred Order of Contact:

    • First: ________________________ Second: _________________________

    • Third: ________________________ Fourth: _________________________

  2. Specific Instructions for Emergencies:

  3. Medical Consent Authorization:
    ☐ Yes, the emergency contact(s) can make medical decisions on behalf of the resident.
    ☐ No, only the Power of Attorney or Guardian can make medical decisions.

Acknowledgement and Consent

  1. I authorize [Your Assisted Living Company Name] to contact the individuals listed above in case of an emergency.
    Resident Signature: ________________________ Date: _________________

  2. I confirm that the information provided is accurate and up-to-date.
    Resident Signature: ________________________ Date: _________________

[Your Assisted Living Company Name]
Phone: [Your Phone Number] Email: [Your Email Address]
Address: [Your Company Address]
Website: [Your Website URL]