Ambulance Victoria Injured or Ill Employee Availability Portal

If you or your employee has been injured or become ill at work, and would like MAX Health to coordinate an appointment with one of our network medical practitioners or physiotherapists, please complete the form below. The information that you provide will help us to organise an appointment as quickly as possible for you. Once you have submitted this form you will receive an email confirming the information you have provided and our Service Delivery team will be in contact with you during business hours regarding your appointment.

Employee Details

Participant First Name *

Participant Last Name *

Date of Birth *

Date of Injury

Gender *

FemaleMaleOther

Employee Number *

Participant Mobile Number *

Participant Alternative Phone Number

Participant Email *

Have you reported the incident to the Duty Manager?

YesNo

Have you logged the incident on HSCS?

YesNo

HSCS/HII Number

* If you have not yet created a HSCS/HII file, please remember to do so as soon as practicable, capturing the workplace incident that requires the InitialCARE services

Briefly describe how you were injured

Have you undertaken any treatment for the injury prior to contacting Injurynet?

YesNo

If YES, please provide details of treatment:

Injury Type *

Mechanism of Injury *

Body Location *

Employer Details

Gippsland Area

Gipps 1Gipps 2Gipps 3

Barwon South-West Region

Barwon South-West 1Barwon South-West 2Barwon South-West 3

Grampians Region

Grampians 1Grampians 2

Comms

BalsecMetro CommsTriage Services

Hume

Hume 1Hume 2Hume 3Hume 4

Manager First Name

Manager Last Name

Manager's Mobile Number

Manager's alternative phone number

Appointment Details

Appointment Type *

Doctor Physiotherapy

Preferred Appointment Location (Please provide suburb and postcode)

Alternate Preferred Appointment Location (Please provide Suburb and Postcode)

MAX Health will endeavour to book an appointment at your preferred location and within the times that you are available, where possible. We request that you provide the earliest times that you are available to attend an appointment. Please note that if you cancel, reschedule or don't attend the appointment, your employer may be charged a consultation fee.

Please provide availabilities within 48 Business hours of your injury/appointment request.

Available Day - First Preference *

Time available from:

Time available to:

Available Day - Second Preference *

Time available from -Second Preference:

Time available to - Second Preference

Available Day - Third Preference *

Time available from - Third Preference:

Time available to - Third Preference

The personal and health information that you have provided as part of the early intervention pilot program will be collected and may be shared with Ambulance Victoria, Ambulance Victoria's workers compensation insurer or representative and any practitioners that you are referred to by this service. This will assist in the management of your injury or illness. For a copy of our privacy statement and details about how this information is collected, used and disclosed please visit www.injurynet.com.au/privacy.

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