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Pricing

Emergency Contact · New

Be Prepared: Collect Resident Emergency & Physician Info

Give your care team fast access to resident emergency contacts, code status, allergies, and physician details. Ideal for assisted living communities.

Use This Template Free Preview

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formbuilder.ai/f/assisted-living-resident-emergency-contact-primary-physician-information-form

Assisted Living Resident Emergency Contact & Primary Physician Information Form

Resident Full Name

· · ·

Date of Birth

· · ·

Room / Apartment Number

· · ·

Submit

The Assisted Living Resident Emergency Contact & Primary Physician Information Form gives your community one organized place to capture the details that matter most when a medical situation arises. Residents and families can record the resident's full name, date of birth, room or apartment number, known allergies and critical medical conditions, and resuscitation preference (code status). The form also lets them upload DNR/POLST orders, advance directives, or healthcare power of attorney documents so care staff have the right paperwork on hand.

Built for assisted living facilities, memory care communities, and senior living residences, this template records the primary emergency contact's relationship to the resident, phone number, email address, and legal authority, plus secondary and additional contacts. A dedicated section captures the primary care physician's name, office phone, and address, along with the resident's preferred hospital for emergency transport. Admissions coordinators, resident care managers, and nursing staff can use it during move-in or as part of routine record reviews.

When every minute counts, scattered paper files and outdated contact lists slow your team down. This online form helps staff and emergency responders act quickly, confidently, and in keeping with each resident's wishes. Families can complete it from any device, and you can easily customize fields, add your branding, and share it by link or email. Keep resident records accurate, accessible, and ready whenever they're needed.

3 Pages

19 Questions

~6min To complete

Free No credit card needed

Field types Full Name ×3 Date ×2 Short Text ×2 Phone ×2 Long Text Single Choice File Upload Dropdown Email Multiple Choice Repeatable Section Address termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Resident Information & Medical Alerts 6 questions

Resident Information & Medical Alerts

Thank you for taking a few moments to share this important information. These details help our care team and emergency responders act quickly, confidently, and in keeping with the resident's wishes if a medical situation arises. Please complete each field as accurately as possible. You can update these records at any time by contacting our Resident Care office.

1 Resident Full Name * Full Name

2 Date of Birth * Date

3 Room / Apartment Number * Short Text

4 Known Allergies & Critical Medical Conditions (enter None if not applicable) * Long Text

5 Resuscitation Preference (Code Status) * Single Choice

6 Upload DNR/POLST, Advance Directive, or Healthcare POA Documents File Upload

Page 2 Emergency Contacts 6 questions

Emergency Contacts

1 Primary Emergency Contact Name * Full Name

2 Relationship to Resident * Dropdown

3 Primary Contact Phone Number * Phone

4 Primary Contact Email Address Email

5 Legal Authority Held by Primary Contact * Multiple Choice

6 Secondary & Additional Emergency Contacts Repeatable Section

Page 3 Primary Physician & Authorization 7 questions

Primary Physician & Hospital Preference

1 Primary Care Physician Name * Full Name

2 Physician Office Phone Number * Phone

3 Physician Office Address Address

4 Preferred Hospital for Emergency Transport Short Text

Authorization & Signature

5 I authorize the facility to contact the individuals and physician listed above, arrange emergency medical care and transport for the resident, and share relevant health information with emergency responders and treating providers as permitted under HIPAA. I confirm this information is accurate and will notify the facility promptly of any changes. * termsandconditions

6 Signature of Resident or Authorized Representative * Signature

7 Date Signed * Date

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.