PPMForm - St Basils Homes

St Basils Homes Pre-Placement Medical Request Form

All sections must be completed for appointments to be processed.

Requestor Details

Requesting Manager’s Name:

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:

Position Applied For:

Worksite:

Service Details

Medical Required:

(For Field Testing Officers and St Basils Homes Safety Testing / Manufacturing Positions only)

Candidate Availability

Do you know when the Candidate/Worker 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:

St Basils Homes Pre-Placement Medical Request Form

Requestor Details

Candidate Details

Service Details

Candidate Availability

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