Patient'S General And Emergency Contact Information Sheet

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Weimar Medical Group, Inc
Patient’s General and Emergency Contact Information Sheet
Please complete this form by indicating a check mark in each section that would be an acceptable manner in
which Weimar Medical Group, Inc. can contact you.

In case of an emergency I authorize Weimar Medical Group, Inc. to contact
at (______) __________-_____________. My relationship to this contact is:
I wish to be contacted by Weimar Medical Group, Inc. in the following manner (please check all areas that would
be an acceptable manner for Weimar Medical Group, Inc. can contact you):

Please contact me on my home telephone: (_______)__________-__________

Weimar Medical Group, Inc. can leave their name and phone number only when they call.

Weimar Medical Group, Inc. can leave a detailed message when they call.

Please contact me on my cellular phone: (________)__________-__________

Weimar Medical Group, Inc. can leave their name and phone number only when they call.

Weimar Medical Group, Inc. can leave a detailed message when they call.

Please contact me at work: (_______) _________-____________

Weimar Medical Group, Inc. can leave their name and phone number only when they call.

Weimar Medical Group, Inc. can leave a detailed message when they call.

Weimar Medical Group, Inc. can mail or email me information such as appointment reminders, and future
clinical sponsored programs.

Weimar Medical Group, Inc. can mail information to my home address.

Weimar Medical Group, Inc. can mail information to my work address.

Weimar Medical Group, Inc. cannot mail information to my home or work address, except
statements of my account.

Weimar Medical Group, Inc. may send me email messages such as appointment reminders at the
following email address:
. (Leave blank if you do not wish to be
contacted via email.)

I herby give permission to Weimar Medical Group, Inc., to release medical information pertinent only to
my current medical condition to: _________________________ relationship:__________________.
Patient’s Name (Please Print)
Signature of Patient, Parent or Legal Guardian
Date

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