Patient Contact Form


What is a patient contact form? 

A patient contact form is an important document that is used to gather contact information about a patient. This form records the name, phone number, email address, address and other relevant details about the patient. It also includes the information of the emergency contact and the details of the primary care physician. The main aim of this form is to make sure that the physician has the relevant contact details of the patient 

Why is this form important? 

A patient contact form is important for the physician to: 

  • Contact the patient in case of emergency 
  • Ensure that the information of the patient is updated 
  • Comply with state and federal healthcare regulations 
  • Provide the best possible care to the patient 

What are the benefits of using this form? 

There are several benefits with respect to using a patient contact form: 

  • It helps the providers keep a track of their patients’ important information, as everything is recorded in one single document  
  • It ensures that the patient can be easily contacted in the case of a follow up treatment or emergency 
  • It allows seamless coordination between the provider and the patient, thereby resulting in improved patient care 
  • It helps providers comply with healthcare regulations 

What details are included in a patient contact form? 

The following details are included in this form: 

  • Patient’s name, phone number, email address, residential address 
  • Information of patient’s primary care physician: name, contact information
  • Emergency contact information: name, phone, address, relationship with patient 
  • Current medications, allergies 
  • Other relevant information
  • Patient’s consent, signature

What are the legal requirements of a patient contact form? 

This form has the following legal requirements: 

  • The patient information must be kept private and confidential and be only released to authorised parties, on a need-to-know basis
  • The form must have the patient’s written consent 
  • The physician must update the patient’s information as per the record-keeping obligations 
  • The physician must use patient information as per the legal requirements