A medical office form template is printed and distributed to employees so they can feel in their details concerning health. This form allows the employers or the company to provide medical assistance when one falls sick at work. This includes signing to approve medical procedures required. It contains someone’s medical history. Below is a sample medical office form template.
Sample Medical Office Form Template
Name___________________Adress________________________Telephone_________________________________
The above named person is an employee of the below undersigned company. The company wishes to have the right to seek medical assistance on the above named person. The relevant company will make medical decisions on his behalf if he is incapacitated.
Name of company ___________________Telephone _______________Address__________________
I hereby confirm that as the company physician, I will take necessary steps to ensure the well being of the above mention employee as far as his health is concerned and advice other doctors accordingly if need be.
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___________________________
