Use this emergency contact form to register contact information of a person close to your patient in case of an emergency.

Customize template

Offer patients a quick and painless way to provide their emergency contact info. There’s no need to call your developer in for adapting this emergency contact form to your needs. The template we provide is easy to edit and provided with a drag and drop option just in case you need more fields. You can also change the design theme or create your own, upload the healthcare facility logo, use an e-signature widget and establish multiple email recipients.

Publish template

Ready to release your form out there? Our publishing tools require nothing more than a copy and paste effort from your side. The form link can be sent by email or embedded on a web page. Moreover, due to its mobile responsiveness, patients can fill it even from their mobile devices.

Collect & manage data

Digital forms are the optimal method for gathering contact information so that communication runs efficiently between medical facilities and relatives or friends in case of emergency. Our template securely stores patient data and offers the ability to also request HIPAA compliance with just a few clicks. Data entries are downloadable in different formats and allow integration with other web apps such as Google Drive, Dropbox, and many more.

Optimize your flow

Medical administrative tasks don’t have to be a chore. Create efficient and responsive emergency contact forms with 123FormBuilder. Browse the settings to find some useful features, including receiving email or SMS alerts when respondents hit the Submit button on the form.