Emergency Contact Form

Emergency Contact Information
Client Name

First Name Last Name
Check this box if you do not wish to provide an emergency contact or next of kin.

I do not have an emergency contact. I am aware that in the event of an emergency, Gentry House and their associates may still try to reach out to my family or contacts in order to provide the best service to me.
Emergency Contact Information

This can be anyone you wish for us to contact first in case of emergency.
Name

First Name Last Name
Relationship to Applicant
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Do you have a separate next of kin to list?

Yes No, my emergency contact is my next of kin. No, I do not have a next of kin.
Next of Kin Information

Please provide contact information for your next of kin in case of medical emergencies where life preserving decisions need to be made on your behalf.
Name

First Name Last Name
Relationship to Applicant
Address

Street Address

Street Address Line 2

City State

Zip Code
Phone Number

Area Code Phone Number
Should be Empty:

Emergency Contact Information