Electronic Occupational Health Referral Form

Referral form for an appointment with an Occupational Health Physician

Last Updated: 12/09/2019

Referring Managers Details

Name *

Reference Number (Please email or phone us if you do not have your company reference number) *

Company name *

Company Address *

Date of referral

Email address *

Telephone *

Mobile

Report to be sent by *

Post

Employee Details

Title *

Miss

Mrs

Other

Gender

Male

Female

Surname *

Forenames *

Date of Birth

Home address

Email address

Telephone - Home

Telephone - Mobile

Telephone - Other

Position

Preferred person and method of contact for booking an appointment (i.e. employee direct by mobile)? *

Due to the new GDPR regulations, you must have the employees consent to share this information with us. Has the employee been informed of the referral? *

Yes No

Referral Details

Reason for referral (Please tick one or more) *

Absence Review – Recurrent Illness

Absence Review – Long Term Sickness

Ill Health Retirement Advice

Advice regarding disabilities

Workplace Assessment

Concern for workplace fitness

Suspected workplace injury or illness

Concern regarding hazards at work

Any specific work issues, have any disciplinary procedures been implemented.

Please give a description regarding the reason for referral (please give as much information as possible) *

Questions

Further details

Any other concerns or issues you would like to be specifically addressed at the consultation and detailed within the report?

Job description - Please give details below or email admin@rosebankmedicalservices.co.uk

Sickness absence record - Please give details below or email admin@rosebankmedicalservices.co.uk

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Electronic Occupational Health Referral Form

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