This form outlines who should be contacted in the event of observed decline, confusion, distress, refusal of help, injury, or other concern. Cedar & Iron is not an emergency responder and will use this hierarchy unless otherwise directed.

Primary Emergency Contact

• Name:
• Relationship:
• Phone Number(s):
• Email (if applicable):
• Authorized to Make Decisions? ☐ Yes ☐ No

Secondary Emergency Contact

• Name:
• Relationship:
• Phone Number(s):
• Email (if applicable):
• Authorized to Make Decisions? ☐ Yes ☐ No

Other Relevant Individuals

(List clergy, neighbors, care managers, etc.)

Escalation Preferences

Please check any preferences that apply:

• ☐ I want family contacted before calling emergency services (if safe to do so)
• ☐ Call 911 immediately in medical emergency without delay