Pre Employment General Form

Role Details

Please provide details about the role

Applicant Details

Please provide your contact details

GP Details

Please provide contact details for your doctor

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 and that if I wilfully suppress any information I risk the loss of appointment.

I understand that by submitting this medical assessment questionnaire I consent to Medmark Occupational Health furnishing the report and notification concerning my fitness to work to my employer / the company from which I'm seeking employment.

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 the personnel department without my consent.

I understand that the report will offer an opinion on my fitness for work and may contain suggested restrictions / alterations/ accommodations to ensure the health and safety of myself and others at work.

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