Emergency Contact Form

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PRIMARY Emergency Contact
List the PRIMARY person you'd like to be contacted in the event of an emergency.
Address of Primary Emergency Contact
Telephone of Primary Emergency Contact*
May Donate Life Northwest discuss your medical information with this individual in the case of an emergency? *
Any important medical information should be disclosed outside of this form to maintain confidentiality. It will be kept kept confidential and shared only on a need-to-know basis and used only in an emergency. 
SECONDARY Emergency Contact
Address of SECONDARY Emergency Contact
Telephone of Secondary Emergency Contact*
May Donate Life Northwest discuss your medical information with this individual in the case of an emergency? *
Any important medical information should be disclosed outside of this form to maintain confidentiality. It will be kept kept confidential and shared only on a need-to-know basis and used only in an emergency. 
Note that this form is NOT strictly confidential and can be viewed by Donate Life NW staff members who have access to the CiviCRM database. If you have a medical condition, medications, or allergies you'd like to disclose confidentially, please reach out to the Operations Director (Sara Lewis / lewissa@ohsu.edu / 503.418.4034) directly so that she may record this information and maintain confidentiality. 
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