Emergency Contact - Emergency/Disaster Priority Code
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client Phone #
Format: (000) 000-0000.
Primary Care Doctor
Fire/Police/Ambulance: 911
Brightstar Care Office: 248-952-9944
Name 1
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
Name 2
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
Name 3
First Name
Last Name
Relationship
Phone
Format: (000) 000-0000.
OFFICE NURSE TO COMPLETE PRIORITY CODE
Priority Code 1 - Client requires full care assistance if disaster strikes
Priority Code 2 - Client requires minimal assistance if disaster strikes
Priority Code 3 - No assistance required if disaster strikes
Marketer Name
First Name
Last Name
Marketer Email
example@example.com
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