Manager and Worksite Details

Requesting Manager's First Name *

Requesting Manager's Last Name *

Requesting Manager's Phone Number *

Requesting Manager's Email *

Worksite

Participant Details

Participant First Name *

Participant Last Name *

Date of Birth

Participant Mobile Number *

Participant Email *

Proposed Job Description

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

Service Required

Medical Required *

Pre-employment medical with Audiometry, Spirometry and Instant Drug & Alcohol Screen

Notes:

Please note:

If you wish to book a medical that differs from the above services, please contact a MAX Health Program Coordinator first on 1300 307 418 or via email ppm@injurynet.com.au
Confirmatory testing on non-negative drug screens can delay PEM results by 2-5 days
Cancellations, reschedules and non-attendances will incur a fee

Privacy

MAX Health collects and uses personal and health information about your candidates / employees for the purposes of providing medical assessment services for your organisation. In making this medical assessment request, you are confirming that the candidate or employee has agreed to their 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.

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