PPMForm - Jet Aviation

Jet Aviation Medical Service Request Form

All sections must be completed for appointments to be processed.

Requestor Details

Manager’s Name:

Contact No:

Email Address:

Invoicing

Cost Account:

Participant Details

First Name:

Family Name:

Date Of Birth:

Mobile Phone No:

Alternate Phone No:

At least one phone number is required

Email Address:

Position:

Worksite:

Service Details

Request Type:

Medical Required:

Please select a minimum of one option

Arsenic Exposure Review (Includes Pathology – Urine Test)

Cadmium Exposure Review (Includes Spirometry & Pathology – Urine Test)

Chromium Exposure Review (Includes skin check)

Crystalline Silica Exposure Review (Includes Spirometry & Chest X-ray)

Isocyanates Exposure Review (Includes Spirometry)

Audiometry (if required as part of medical examination)

Participant Availability

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

Injurynet will contact the participant 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 participant'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: