Occupational Health – Candidate Consent Form

Candidate Consent Form

Your employer has asked me to see you today. The reason for this consultation is to provide your employer with my medical opinion on the following:

Any medical reason for absence from work
When, or if, you will be able to return to work
If any restriction should be applied to your work on medical grounds

Following our consultation and only with your consent, I will send a copy of my findings to your employer, who will be responsible for its confidentiality. I will only include information that is relevant to the assessment. I will discuss my findings with you at the end of the consultation and you can ask me any questions you may have about my opinion. If you consent to this, please sign below:

Name(Required)

First Last

I may need to contact your own GP to clarify medical information. If you consent to this, please fill out your GP details and sign the consent at the end of this section.

Your GP Name

Address of your GP practice

Are you a robot

(091) 530054

info@GalwayBayMedicalCentre.ie

Occupational Health – Candidate Consent Form

Candidate Consent Form

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