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Emergency Contact & Medical Information

Used in the event of a medical or behavioral emergency.

Kura Solution

Appendix F — Emergency Contact & Medical Information

Used in the event of a medical or behavioral emergency.

Resident Name *

Emergency Contacts

Primary Contact Name

Phone

Relationship

Secondary Contact Name

Phone

Medical

Primary Care Provider

Pharmacy

Allergies

Medical Conditions

Medications

Insurance / Medicaid ID

Resident Signature

Resident Signature *

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Resident Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.