Name: Buster Zztest | DOB: 6/15/1953 | MRN: 14331292 | PCP: Patricia G. HINZ MD

Emergency Contact Update

Who would you like us to call if you have a medical emergency?
*Please note that the emergency contact must be an adult who knows how to reach you.

We may use the emergency contact information to locate you if your physician needs to contact you with important medical information, but cannot reach you.

If you have a medical emergency and need to be sent to the hospital, while visiting PAMF, it is important that we have someone to speak with regarding your care and well-being.

Please take a moment to update the emergency contact form. The information you provide will help us provide you with better care and peace of mind.
Emergency contact 1
Name:  Home Phone:  (e.g. 333-333-3333)
Relationship:  Work Phone:  (e.g. 333-333-3333x1234)
Emergency contact 2
Name:  Home Phone:  (e.g. 333-333-3333)
Relationship:  Work Phone:  (e.g. 333-333-3333x1234)
Guardian (applies only if legal guardianship is established)
Name:  Home Phone:  (e.g. 333-333-3333)
Relationship:  Work Phone:  (e.g. 333-333-3333x1234)


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