Night and Shift Workers Health Assessment Form

Night or Shift Worker Details

Shift Details

Please provide some details about your shift and the hours worked

Price

Payment Method

Declaration

I declare that the information I have given is true and complete to the best of my knowledge and that I have not withheld any material facts. I understand that I am responsible for the accuracy of my statements.

I consent to Medmark contacting my general practitioner or any health professional who attended me concerning anything which affects my physical or mental health.

I understand that relevant details of my personal or medical history will not be disclosed to anyone without my consent.

By submitting this document to Medmark I understand, accept and consent to all of the above