Medical Consent Form

We have been asked to contact you in order to prepare a report regarding your fitness for work. The request has been made by your employer and will be carried out on their behalf.

You do not have to agree to this. However if you do not, we will be unable to speak to you, and your employer will not have the up-to-date medical information they need.

Following your consultation a report of relevant findings will be prepared regarding your current state of health and your future outlook, based on any information provided by your own doctor, consultants, any information you provide and the findings of our examination.

We may leave out personal or sensitive information deemed irrelevant to your particular employment. However, it is not always easy to see what will be relevant, and you should be aware that any or all information may form part of the report.

You have the right to see the report. You also have the right to challenge what you may believe are factual inaccuracies. In the event of a factual inaccuracy that may affect the outcome of the report, we can amend the report. If you do not agree with the doctor’s opinion, the report will not be amended but a statement of your views can be attached to it.

Please indicate which option you would like us to take

Send report directly to employer

Send me a copy of the report at same time as sent to employer

Would like to review report prior to it being sent to employer?*

*Please note under this option the report will be sent to your employer 48 hours after it has been sent to you

Your Email

Please supply your personal email address if ticking options 2 or 3

Print Name(Required)

Signature(Required)

Date(Required)