Employee Onboarding Form

Please complete the following information in its entirety and review for accuracy to ensure smooth onboarding at Outdoor Therapeutics. Please contact krista@outdoortherapeutics.com if you have questions.

PERSONAL INFORMATION

Legal First Name

Legal Middle Name

Legal First Name

Current Address 1

Current Address 2

Current Town/City

Current Zipcode

Previous Address 1

Previous Address 2

Previous Town/City

Previous Zipcode

Personal Phone Number

Personal Email Address

Date of Birth

Social Security Number

EMERGENCY CONTACT INFORMATION (ICE)

Full Name

Relationship to Employee

ICE Town/City

Personal Phone Number

Personal Email Address

CLINICAL IDENTIFICATION

License ID #1

Liense ID 2

License Start

License Expiration

National Provider ID (NPI)

CAQH ID

Please review before submitting

Upload MD License

Upload supported file (Max 15MB)

License in Good Standing

Upload Verification