DJCS Victoria - Medical Booking Request Form

Please fill out the following form
Once a request is received, MAX Health will reach out to you for availabilities (if not provided ) within one business day. Upon receiving availabilities, a booking confirmation will be sent to you with your appointment details within 2 business days.
MAX Health will confirm the appointment with you and forward you:
- A pathology referral form to take to the pathology collection centre and;
- A health questionnaire to print, complete and take to the examination with you
Pathology needs to be completed 2 weeks prior to the medical examination. The Pathology appointments will be booked at a Pathology clinic within MAX Health's network of providers.

Participant Details

Participant First Name *

Participant Last Name *

Date of Birth

Participant Mobile Number *

Participant Preferred Email *

I declare that I have not exceeded my executive health check entitlement under my executive contract this year. That is to say, I have not received an executive health nor have I claimed a health check reimbursement this year. *

Health Check Appointment Availabilities

Note: Pathology must be attended a minimum of two weeks PRIOR to th Health Check to ensure results are available

Preferred Location (Provide suburb & postcode)

Alternate Location (Provide suburb & postcode)

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

Privacy

MAX Health collects and uses personal and health information for the purposes of providing medical assessment services for your organisation. In making this medical assessment request, you are confirming that you agreed to your personal information being disclosed to us. If you would like more information about how we manage, collect, hold, use and disclose personal information, please refer to our Privacy Statement.

Save and Complete Later