* Required fields

All sections must be completed for appointments to be processed

Requestor Details

Invoicing

Candidate Details

Please note: If the candidate's email address is supplied then a copy of the appropriate Pre-Placement Medical Forms will be emailed to the candidate upon submission of this request.

Type of service required (select one)

If you wish to book a medical that deviates from the above services you MUST contact an InjuryNET PPM Program Coordinator first on (03) 9500 9968.