Medical Assessment Change of Appointment Request

Please complete and submit the following form to request a reschedule or cancellation of your appointment(s)
Please note: Any cancellation or reschedule may incur a fee which will be charged to your employer or prospective employer, so it’s important that you make every effort to attend your booked appointment(s)

Participant Details

Participant First Name *

Participant Last Name *

Date of Birth *

Participant Mobile Number *

Participant Email *

Employer or Prospective Employer *

Injurynet ZW Reference Number

Change of Appointment

Appointment time and date that you would like to change *

Do you have any other appointments to cancel or reschedule?

No Yes

Second appointment the you would like to change

Third appointment that you would like to change

Fourth appointment that you would like to change

I would like to: *

Reschedule my appointmentCancel my appointment

Please provide a brief explanation *

Preferred Location (Provide suburb) *

State *

Postcode

Alternate Location (Provide suburb) *

State: *

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 *

I understand that any cancellation or reschedule may incur a fee which will be charged to my employer or prospective employer *

Please note:

If you wish to make a change that differs to the above options, please contact Injurynet on 1300 307 418 or via email ppm@injurynet.com.au
Reschedules may be subject to employer or prospective employer approval and appointment availability

Save and Complete Later