Emergency Phone Numbers

Date:

Employee:

In the event of a medical emergency, the following people and emergency medical personnel should be contacted:

Contact 1:

Phone No.:

Relationship:_

Contact 2:

Phone No.:

Relationship:

Doctor:

Phone No.:

Insurance & Medicare Identification No.:

Health/Medical History:

Medication Taken and Allergies:

Please complete and return to the Personnel Department.

Contract law requirements

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