PPMForm - McKenzie PPM

McKenzie Aged Care Group Medical Request Form

All sections must be completed for request to be processed.

Requesting Manager Details

Name:

Phone:

Email Address:

Worksite Details

Job Description:

Worksite:

Dept GL/Cost Centre Code:

Candidate Details

First Name:

Family Name:

Date Of Birth:

Mobile Phone Number:

Alternative Phone Number:

At least one phone number is required

Email Address:

Service Details

Medical 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, reschedules 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: