Emergency Contact & Medical Alerts

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Person Served Emergency Contact

Section 1: Patient Information

Please provide your current personal and contact details to ensure your medical records remain accurate and up-to-date.

Full Name

Gender

SSN

Address Details

Home Phone Number

Work Phone Number

Section 2: Emergency Contacts

List the primary individuals you authorize us to reach out to in the event of a medical or psychiatric emergency.

Primary Contact: Emergency Contact #1

Full Name

Relationship

Address

Phone Number

Primary Contact: Emergency Contact #2

Full Name

Relationship

Address

Phone Number

Section 3: Current Medical Providers

Please share the contact information for your current therapist and psychiatrist so we can safely coordinate your overall care.

Therapist Details

Therapist Name

Address

Phone Number

Psychiatrist Details

Psychiatrist Name

Address

Phone Number

Section 4: Health & Medical Alerts

List any known health conditions, allergies, and your current medications to ensure we provide the safest possible support.

Health Alerts

Medications

Section 5: Emergency Preferences & Consent

Indicate your preferred hospital or physician for emergency situations, and authorize Jay Care to share necessary information with them if an emergency occurs.

It is my preference that such treatment is provided by the following physician and/or hospital.

Physician Name

Address

Phone Number

Emergency Contact Consent

I understand that in the event of any emergency, as defined by staff, attempts will be made to contact any of the above for the purposes of notification.

Release of Information

I also freely give consent for Jay Care Mental Health Center to release to the above provider's pertinent information relevant to such treatment.

Section 6: Authorization & Signature

Please review your information and provide your digital signature below to authorize this emergency contact and consent form.

Patient Signature

Sign Here

Date

Witness Signature

Sign Here

Date

Emergency Contact & Medical Alerts

Home > Forms Hub

Section 1: Patient Information

Section 2: Emergency Contacts

Section 3: Current Medical Providers

Section 4: Health & Medical Alerts

Section 5: Emergency Preferences & Consent

Section 6: Authorization & Signature

8508 Loch Raven Blvd, Towson, MD 21286

info@jaycarementalhealthcenter.com

1 (443) 275-2354

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