You can use this emergency information form to create records of medical conditions, insurance and other related information you require about your patient. Customize the template in your 123FormBuilder account and share it anywhere on the web with a simple copy and paste.

Customize template

Offer patients or employees a painless way to enter their emergency info. No need for technical skills in order to adapt this emergency information form to your needs. Our prebuilt form sample works with drag and drop, in case you need more fields or other form elements. You can also change the form’s design with just a few clicks. Then upload your logo, configure autoresponders and establish multiple email recipients.

Publish template

Ready to release your emergency information form? Our publishing options require nothing more than a copy and paste effort from your side. The form link can be sent by email or posted on social media pages or groups. Of course, the generated form code easily embeds on your website. Plus, due to mobile responsive design, the form is easy to fill out from just about anywhere.

Collect & manage data

The 123FormBuilder platform securely stores patient data in a database attached to your online form. Naturally, you also get the option to also request HIPAA compliance with just a few clicks. Data entries are downloadable in Excel, CSV or PDF format and allow integrations with other web apps.

Optimize your flow

Digital forms are the bread and butter of modern-day workflows. They are the optimal choice for gathering emergency information so that communication runs smoothly in case of emergency. And you also get real-time alerts each time someone hits the Submit button on your emergency information form.