2020-21 Staff Emergency Medical Form – Ohio Hi-Point Workflows

Employee Emergency Medical Form

Name
First Last
Date of Birth*
Date Format: MM slash DD slash YYYY
Home Address*
Street Address Address Line 2 City State ZIP Code
Medical Insurance*
Family Doctor Name
Family Doctor Phone
Dentist Name
Dentist Phone
Notes
Please indicate any facts concerning your medical history, including but not limited to: allergies, medications taken regularly, and any physical impairment in which a physician should be alerted. Please note - All information is confidential and will only be used in case of an emergency.
Do you wear contacts?
- Yes
- No
In the event that you become ill or injured at work, we will transport you to Mary Rutan Hospital for immediate care, and the individual below will be notified. Please specify the nearest relative or other person that we should notify in this case.
Contact Name
First Last
Contact Relationship
Contact phone during working hours
Contact home or cell phone