Employee Emergency Contacts
Employee Information
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Date of Hire
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Job Title
*
Please Select
Dental Assistant
Dental Hygienist
Sterilization
Front Office
Dentist
Office Manager
Primary Emergency Contact
Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Employee:
*
Secondary Emergency Contact (Optional)
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Employee:
Medical Information (Optional but recommended)
Used for communication in an emergency situation
Would you like to provide relevant Medical Information for emergency communication?
*
Yes
No
Allergies:
(medications, food, etc.):
Medical Conditions:
(e.g.,asthma, diabetes)
Current Medications:
Preferred Hospital:
Primary Care Physician Name:
Primary Care Contact #:
Please enter a valid phone number.
Format: (000) 000-0000.
Employee Acknowledgment“I certify that the above information is accurate and I give permission for Kennebec Valley Dental Arts to contact the individuals listed above in the event of an emergency.”
*
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