Occupational Health Form

Referral Form

Section 1

Instruction Type

*Light Touch or Comprehensive Report?

*Remote, Face to Face or Either?

*Referring employer/business name

*Referring employer/business address

Referrer contact details

*Direct dial

*Mobile

*Email

*Date of referral

Section 2

*Employee name

*Employee address

*Post code

*Date of Birth

Employee contact number

*Land line

*Mobile

*Email

*Preferred initial contact method with employee

Section 3

*Reason for referral

Date of injury/onset of illness (If applicable)

Length of absence (If applicable)

Absence trend (If applicable)

*Nature of injury/illness/condition

*Occupation/job role

*Job description

*Copy of job description disclosed

*Contracted hours of work per week

*Work pattern

Section 4

*Medical records

*The reason for this referral has been discussed with the employee and they have provided their consent for the assessment?

*Copy of employee consent disclosed

*Please list any specific questions to be addressed in the assessment

*Employers perception on working practice or return to work

Current fit note details (if applicable)

Date assessed

Condition Stated

Expiry Date

Any additional information

Attach a Document

Please can you request that the employee brings any clinical information/ letters, prescriptions or any other information with them to the appointment to assist with the assessment?

To enquire please call

0330 094 8749