A medical office form is often issued by employers to their employees asking them to give them the right and permission to seek medical care on their behalf if they are injured or get sick in the course of duty. This form allows the employer to take you to hospital and also sign medical procedure papers on your behalf. Below is a sample medical office form.
Sample Medical Office Form
Name___________________Adress________________________Telephone______________________
This is to confirm that I, the party whose name appears above is an employee of the below undersigned company and I hereby give the relevant authority consent to seek medical treatment on my behalf whenever necessary.
Name of company ___________________ Telephone _______________ Address__________________
I on behalf of the above stated company hereby confirm that the named person is our employee and has given the company and its physician the authority to provide medical assistance.
Name of company signing authority __________________ Telephone__________________________
Name of insure __________________________Telephone_______________
Insurance policy ____________________Insurance policy Number___________________________
List of medication previously used____________________________
Description of medical history_______________________________
List of diseases suffered previously___________________________________
Surgeries_______________________________ Date of surgery_________________________
Allergies_______________________
Telephone_______________________________________
Emergency contact telephone _____________________________________
Next of kin ____________________Telephone___________________________
