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Employee Disclaimer Form

This document contains an employee disclaimer form for a dental associate joining The Local Dentist. It includes the associate's personal details like name, education and registration details, addresses and contact information. It also lists the associate's key responsibilities like conducting camps, assisting senior doctors, following leave schedules, accurately reporting all patient and financial transactions, avoiding self-promotion, honoring the agreed tenure and timings, and providing one month's notice prior to resigning. The associate accepts understanding and agreeing to these terms and confirms that the information provided is true and accurate.

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Dr.Aparna Pratik Dalal
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© © All Rights Reserved
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53 views2 pages

Employee Disclaimer Form

This document contains an employee disclaimer form for a dental associate joining The Local Dentist. It includes the associate's personal details like name, education and registration details, addresses and contact information. It also lists the associate's key responsibilities like conducting camps, assisting senior doctors, following leave schedules, accurately reporting all patient and financial transactions, avoiding self-promotion, honoring the agreed tenure and timings, and providing one month's notice prior to resigning. The associate accepts understanding and agreeing to these terms and confirms that the information provided is true and accurate.

Uploaded by

Dr.Aparna Pratik Dalal
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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EMPLOYEE DISCLAIMER FORM

MY NAME IS ______________________________________________________________________________.

MY EDUCATIONAL QUALIFICATIONS
ARE_______________________________________________________________________________________

MY DENTAL COUNCIL REGISTRATION NUMBER ALONG WITH THE NAME OF THE


COUNCIL___________________________________________________________________________________

YEAR OF GRADUATION AND COLLEGE NAME_____________________________________________________

ADDRESS OF PRESENT WORKPLACE_____________________________________________________________

MY PRESENT RESIDENTIAL ADDRESS


__________________________________________________________________________________________

__________________________________________________________________________________________

MY PERMANENT RESIDENTIAL ADDRESS


_________________________________________________________________________________________

__________________________________________________________________________________________

MY EMAIL ID _______________________________________________________________________________

MY LANDLINE PHONE NUMBER________________________________________________________________

MY MOBILE NUMBER__________________________________________________________________

MY AADHAR CARD NUMBER__________________________________________________________________

DISCLAIMER

I UNDERSTAND AND ACCEPT MY DUTIES AND RESPONSIBILITIES AS THE ASSOCIATE AT ‘THE LOCAL DENTIST’
INCLUDING BUT NOT LIMITED TO:

 CONDUCTING CAMPS IN VARIOUS LOCATIONS IN ACCORDANCE WITH THE CLINIC SCHEDULE


MAINTAINING MY OWN TRANSPORT.
 ASSISTING THE SENIOR DOCTORS IN VARIOUS DENTAL PROCEDURES
 FOLLOWING A ONCE A WEEK LEAVE SCHEDULE NOT LIMITED TO SUNDAYS ALONE IN HARMONY
WITH THE OTHER EMPLOYEES AT ‘THE LOCAL DENTIST’
 REPORT HONESTLY AND IN DETAIL ALL THE PATIENT FINDINGS AND TRANSACTIONS INCLUDING ALL
FINANCIAL TRANSACTIONS WITHOUT TRYING TO WITH HOLD ANY INFORMATION.
 WILL STRICTLY STAY AWAY FROM SELF PROMOTION.
 WILL HONOUR AND MAINTAIN THE TENURE, TIMINGS AND FINANCIAL CONTRACT AGREED UPON
BETWEEN MYSELF AND THE OWNER OF ‘THE LOCAL DENTIST’
 WILL PROVIDE A MINIMUM OF ONE MONTH’S NOTICE PRIOR TO LEAVING, AFTER THE DATE OF MY
RESIGNATION IN CASE I INTEND TO TERMINATE MY EMPLOYEMENT AT ‘THE LOCAL DENTIST’

I ACCEPT THAT I HAVE UNDERSTOOD THE ABOVE TERMS AND AGREE TO THE SAME.
I ALSO AGREE THAT THE DOCUMENTS AND THE INFORMATION I HAVE PROVIDED ABOVE IS TRUE
AND ACCURATE TO THE BEST OF MY KNOWLEDGE.

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