Djinda Health Medical Assessment Booking Form
Date and time of this request
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Day
-
Month
Year
Date
Hour Minutes
Metro Clinics
Please Select
Wanneroo (WA)
Midland (WA)
Perth Airport (WA)
Perth Central City (WA)
Riverton (WA)
South Perth (WA)
Rockingham (WA)
Bunbury (WA)
Regional Clinics
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Geraldton (WA)
Karratha (WA)
Kalgoorlie (WA)
Port Hedland (WA)
Broome (WA)
Interstate Clinics
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Darwin (NT)
Alice Springs (NT)
Adelaide (SA)
Cairns (QLD)
Townsville (QLD)
Mt Isa (QLD)
Gold Coast (QLD)
Brisbane (QLD)
Toowoomba (QLD)
Port Curtis (QLD)
Sydney (NSW)
Parramatta (NSW)
Newcastle (NSW)
Melbourne (VIC)
Geelong (VIC)
International Clinics
Please Select
Auckland (NZ)
Hamilton (NZ)
Christchurch (NZ)
Charlotte, NC (USA)
Person/Recruiter submitting the request
*
Name
Company
Person/Recruiter Contact Email Address
*
example@example.com
Person/Recruiter Contact Phone Number
*
Preferred Date for Medical
*
-
Day
-
Month
Year
Date
Preferred Appointment Time
*
Please Select
Morning
Afternoon
Anytime
Alternative Date for Medical (Optional)
-
Day
-
Month
Year
Date
Alternative Date for Medical (Optional)
Please Select
Morning
Afternoon
Anytime
Any comments that you feel will help us find the location and time for your candidate's appointment
Candidate's Details
Candidate's Name
*
First Name
Last Name
Candidate's Date of Birth
*
/
Day
/
Month
Year
Date
Candidate's Contact Phone Number
*
Candidate's Email Address
*
example@example.com
Candidate's Proposed Role
*
Proposed Job Location / Site
*
Purchase Order Number (If applicable)
Please select all Medical Assessment Services required:
*
STANDARD MEDICAL + FUNCTIONAL - (Components: medical, musculoskeletal & fitness, regulatory audio, spiro)
BASIC MEDICAL + FUNCTIONAL - (Components: medical, musculoskeletal & fitness)
COMMERCIAL DRIVER'S MEDICAL -including regulatory audio
RAIL CAT 1 - including regulatory audio, resting ecg, bloods
RAIL CAT 2 - including regulatory audio
RAIL CAT 3 - including regulatory audio
OEUK (formerly OGUK) - including regulatory audio
SAFER TOGETHER MEDICAL - including regulatory audio
FUNCTIONAL CAPACITY EVALUATION - musculoskeletal & fitness
LAB DAS
INSTANT DAS
SPIROMETRY
AUDIOMETRY (regulatory)
OTHER (please tick box for Respirator or Earplug Fit ONLY)
RESPIRATOR FIT TESTING
Please Select
Mask Fit - 3M 7500
Mask Fit - 9322A + P2
Mask Fit - N95
Mask Fit - P2
Mask Fit - P3 (full face)
Mask Fit - RWRX251 P2
Mask Fit - SR 100
Mask Fit - SR 900
Mask Fit - Trident P2
EARPLUG FIT TESTING
Please Select
Ear Plug Fit Test
Telfer Ear Plug Fit Test
Additional Notes / Questions
Please use the below option to attach business specific paperwork for the Medical Assessment (if required)
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24hrs notice is required for cancellations. Cancellations and 'No Show' appointments booked with our alliance clinics, may incur charges. Charges may vary between clinics.
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