Occupational Health Bookings - Brecken Bunbury -

Company Name *

Company Booking Officer *

Company Booking Officer Email

Company Contact Number *

Email to send results to *

Billing Company (if different)

Comments

Candidate's Name *

First Last

Job Role (if known)

Type of Medical / Assessment *

Health Surveillance Medical

Please call the Corporate Team to discuss further.

Functional (if applicable)

With Fitness
Without Fitness
Fitness Only

Audiometry (if applicable)

Standard
Regulation 58 Reference Audiometry Testing
Regulation 58 Monitoring Audiometry Testing
Regulation 58 Monitoring Re-Test (Local Companies Only)

Reference Testing: Please ensure candidate has completed 16 hours of quiet time, prior to the test.Monitoring Testing: Please ensure that the candidate has completed at least 50% of their shift completing their usual duties with usual hearing protecting prior to test. Candidate MUST travel directly to the clinic.Monitoring Re-test: Please ensure candidate has completed 16 hours of quiet time, prior to the test.

Spirometry (if applicable)

Yes
No

Drug and Alcohol (if applicable)

ECG (if applicable)

Yes
No

Blood Testing (if applicable)

HBA1c – Fasting
HBA1c – Non-Fasting
Total Cholesterol HDL / LDL – Fasting
Total Cholesterol HDL / LDL – Non-Fasting

Chest X-Ray (if applicable)

Standard
ILO Reporting

Chest CT Scan (if applicable)

Yes
No

Travel Medical and Vaccinations (if applicable)

Yes
No

Please call the Corporate Team to discuss further.

Q Fever (if applicable)

Yes
No

Comments

PO Number

Preferred Booking Date

Preferred Booking Time

Morning (AM)
Afternoon (PM)
Any

Comments

Medical Paperwork

Use Brecken Health Paperwork
Use Company specific Paperwork – please upload below.

Paperwork

Drop files here or

Max. file size: 25 MB.

If there is specific paperwork required, please upload here.

Corporate Bookings