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FH-CL-005 • VERSION 1.0
Emergency Contact & Emergency Information
Contacts, safety information, access and emergency preferences.
Digital workflow:
Complete required fields, review carefully, then submit. A submitted record is timestamped and preserved for office review.
1. Record identification
Client name *
Date *
Completed by *
2. Client & contacts
Preferred name
Date of birth
Service address
Primary emergency contact
Secondary emergency contact
Authorized representative
3. Emergency information
Preferred hospital / provider
Allergies, mobility, fall and communication needs
Emergency-relevant medications (information only)
Entry / lockbox instructions
Pets, oxygen, fire risks and hazards
911 and contact-order preferences
Advance directive location
No-answer procedure
4. Certification / acknowledgment
Electronic signature / typed name *
Signature date *
Notes
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