PPMForm - Adaptalift

Adaptalift Group Medical Service Request Form

All sections must be completed for appointments to be processed.

Requestor Details

Requesting Manager:

Contact No:

Email Address:

Candidate Details

First Name:

Family Name:

Date Of Birth:

Mobile Phone No:

Alternate Phone No:

At least one phone number is required

Email Address:

Job Description:

Worksite

Division:

Worksite:

PO Number:

Service Details

Medical Service Required:

Candidate Availability

Do you know when the candidate is available to attend a medical?

Injurynet will contact the candidate to obtain their availability and location for the medical.

Please select at least 9 hours over a minimum of 2 weekdays. If you would like to add additional days to your selection please click on +.

Injurynet will book the candidate's medical based on the date and times you have provided. Please note, all cancellations and non-attendances will incur a fee.

Day 1:

Day 2:

Day 3:

Day 4:

Day 5:

Day 6:

Day 7:

Day 8:

Day 9:

Preferred Location:

Alternative Location:

Additional Notes:

Privacy

Injurynet collects and uses personal and health information about your candidates / employees for the purposes of providing medical assessment services for your organisation. In making this medical assessment request, you are confirming that the candidate or employee has agreed to their personal information being disclosed to us.
If you would like more information about how we manage, collect, hold, use and disclose personal and health information, please refer to our Privacy Statement.