Queensland Ambulance Service

Participant Medical Assessment Request

Thank you for choosing MAX Health to organise your Queensland Ambulance Service medical assessment.

To help us to book your assessment, please provide us with your preferred assessment location, your availability & medical assessment payment. Once this form and payment are submitted, we will book your assessment and send you further information confirming your assessment.

Participant Details

Participant First Name *

Participant Last Name *

Date of Birth *

Participant Mobile Number *

Participant Email *

QAS Application or Student ID Number *

University

Service Required

Medical Assessment Required *

Undergraduate Clinical Placement Medical AssessmentQualified Paramedic Medical AssessmentGraduate Paramedic Medical AssessmentPatient Transport Officer Medical Assessment

Please note:

If you wish to book a medical that differs from the above services, please contact an MAX Health Program Coordinator first on 1300 307 418 or via email workplace.health@maxsolutions.com.au

Location Preferences

The cost of your medical assessment is determined based on the location where the assessment is conducted. Please indicate your preferred location to complete your assessment.

Choose your preferred State for assessment *

Choose your preferred South Australian location for assessment *

Adelaide SAElizabeth SARoyal Park SAStepney SA

Choose your preferred TAS location for assessment *

Hobart TASLaunceston TAS

Choose your preferred NT location for assessment *

Darwin NT

Choose your preferred ACT location for assessment *

Canberra ACT

Availability

Please provide us with some information about when you are available to attend an assessment. MAX Health will endeavour to book your assessment based the days and times you have provided and within a reasonable distance of your preferred location.

We recommend that you provide as many days and times as you can so that we can organise a suitable assessment for you. Ideally we request at least nine hours over a minimum of three business days.

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 *

Submit additional availability

Available Day - Fourth Preference

Time available from - Fourth Preference

Time available to - Fourth Preference

Available Day - Fifth Preference

Time available from - Fifth Preference

Time available to - Fifth Preference

Do you have any disability or accessibility requirements to access your medical assessment?

YesNo

Please outline your needs

Medical Assessment Payment Information

Medical Assessment Payment - $269.50 (Metro Clinic Pricing)

Payments accepted via credit card. Payment must be made in full prior to booking. Payment details will be provided upon submission of this request. Call us on 1300 307 418 or email wokplace.health@maxsolutions.com.au should you have any questions.

Medical Assessment Payment - $350.35 (Non - Metro Clinic Pricing)

Payments accepted via credit card. Payment must be made in full prior to booking. Payment details will be provided upon submission of this request. Call us on 1300 307 418 or email wokplace.health@maxsolutions.com.au should you have any questions.

Your Medical Assesment Cost

Your Medical Assessment Cost

Medical Assesment Payment Calculation

Medical Payment Card Details *

Cancellation and Reschedule Fees

Please be advised that any discrepancy between the medical fee payment and the cancellation or rescheduling fees outlined below will be reimbursed by MAX Health to the credit card used for the initial payment.

		Fee per applicant (Metro Region (Including GST)	Fee per applicant (Non - Metro Region (Including GST)
Non - Attendance	Missed appointments, cancellations or reschedules ≤ 3 business hours of the scheduled appointment time.	$202.13	$262.77
Late Cancellation	Cancellations or reschedules > 3 business hours but ≤ 24 hours of the schedule appointment time.	$134.75	$175.18
Cancellation	Appointments that are cancelled > 24 hours of the schedule appointment time.	$55.00	$55.00
Reschedule	Appointments that are reschedule > 24 hours of the scheduled appointment time.	First = FREE Subsequent = $55	First = FREE Subsequent = $55

Privacy

MAX Health collects and uses personal and health information about you for the purposes of providing medical assessment services to Queensland Ambulance Service. In making this medical assessment request, you are confirming that you agree 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.

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