QUOTE REQUEST FOR OCCUPATIONAL HEALTH MEDICALS

Please complete & submit this brief Man-job Specification Form, and we’ll send you a quote soonest.

Please complete all fields:

Client name (Required)

Contact no. (Required)

Contact person (Required)

Email address (Required)

Medicals due date (Required)

Location

Medicals to be done:

Onsite (mobile clinic)Local clinic*

*If local clinic, in which location?

Which physical requirements are in high demand?

Climbing stairs

Climbing ladders

Hearing

Handling delicate equipment

Lifting heavy equipment

Vision specificity

Night vision

Bio-mechanical requirements

Repetitive work

Working at heights or depths

Environmental exposures

Temperature extremes	High humidity
Dust	Gas/Fumes
Hazardous substances	Dampness
Radiation	Vibration
Abnormal positions	Confined spaces
Noise*	*How many employees need audiograms?

Chemical exposure (please list chemicals)
Specific tests & investigations required (please specify)
Brief description of job/s for which employees/applicants/contractors are employed

No. of employees to be tested

Preferred day/s & time for appointment

Monday	AMPM
Tuesday	AMPM
Wednesday	AMPM
Thursday	AMPM
Friday	AMPM

ANY OTHER COMMENTS?

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(To request a medical quote, please click here):

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