Emergency Contact Accept Emergency Contact Acceptance Form Client NameThe name of the client in which you have been listed as an emergency contact. First Last Your NameYour name as the listed emergency contact. First Last Email Cell PhonePlease include your preferred cell phone. In the case of an emergency, and for appointment reminders, a text message will be sent to this number.Your Relationship Family Friend Neighbor Do you agree to be added as an Emergency Contact?* Yes No
