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Dutch Springs Staff

Medical Information Document

Please answer the below questions regarding your medical status. 

This form will be kept on file in the admissions office so that, in the event of an emergency, we can quickly and easily review important information about your medical history.

***if your medical status changes please update this form by submiting a NEW medical information document***

 

By signing this form you indicate that all of the information provided is correct.

 

November 15, 2019

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First Staff's Name

First Name*

Last Name*

Phone*
First Staff's Date of Birth*
First Staff's Medical Information
ALLERGY INFORMATION:

Do you have any allergies to the following?
Bees*
No
Yes
Medications*
No
Yes

If yes, please the medications you are allergic to.
Food*
No
Yes

If yes, please list the foods you are allergic to.
Any Other Allergies (example: latex)*
No
Yes

If yes, please list any other allergies.
Do you use an EPI pen?*
No
Yes
Do you use an inhaler?*
No
Yes


CURRENT HEALTH STATUS

Do you have any chronic conditions that may hinder your ability to work?*
No
Yes

If yes, please explain your chronic conditions
Do you currently take any medications?*
No
Yes

If yes, please list the medications you currently take.


EMERGENCY CONTACT INFORMATION

Primary Emergency Contact:


Full Name

Phone Number

Relationship to Staff Member

Secondary Emergency Contact:


Full Name

Phone Number

Relationship to Staff Member


CONSENT

If you are injured or need medical attention, may we provide this information to the necessary personnel to ensure you the best care?*
No
Yes
First Staff's Signature*
Staff's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Medical Information
ALLERGY INFORMATION:

Do you have any allergies to the following?
Bees*
No
Yes
Medications*
No
Yes

If yes, please the medications you are allergic to.
Food*
No
Yes

If yes, please list the foods you are allergic to.
Any Other Allergies (example: latex)*
No
Yes

If yes, please list any other allergies.
Do you use an EPI pen?*
No
Yes
Do you use an inhaler?*
No
Yes


CURRENT HEALTH STATUS

Do you have any chronic conditions that may hinder your ability to work?*
No
Yes

If yes, please explain your chronic conditions
Do you currently take any medications?*
No
Yes

If yes, please list the medications you currently take.


EMERGENCY CONTACT INFORMATION

Primary Emergency Contact:


Full Name

Phone Number

Relationship to Staff Member

Secondary Emergency Contact:


Full Name

Phone Number

Relationship to Staff Member


CONSENT

If you are injured or need medical attention, may we provide this information to the necessary personnel to ensure you the best care?*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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