PPMForm - DET Booking Request Portal

Department of Education and Training - Principal Health Checks

Once you have submitted this form you will receive an email confirming the information you have provided and instructions for attending your appointment. If you do not receive this email, or the information you have provided is incorrect, please contact InjuryNET during business hours on (03) 8396 0266.

Personal Details

First Name:

Family Name:

Date Of Birth:

Gender:

Mobile Phone Number:

Alternative Phone Number:

At least one phone number is required

Preferred Email Address:

Do you wish to have the summary report emailed to the email address provided?:

Injurynet will send the summary report in the mail, please provide your postal address:

Street Address:

Suburb:

Job Description:

If your job description is not listed, please provide the title in the space below

Region:

School Name:

If your school is not listed, please provide the name in the space below

Have you previously completed a Health Check coordinated by Injurynet?:

Availability

Your Health Check consists of two appointments, spaced approximately two weeks apart. The first appointment will be a blood test and may include and ECG; Injurynet recommends this is completed in the morning due to fasting blood component. The second appointment will be a Doctor.

Appointment 1

Day 1:

Day 2:

Day 3:

Day 4:

Day 5:

Day 6:

Day 7:

Day 8:

Day 9:

Preferred Location:

Alternative Location:

Appointment 2