Oil & Gas UK Medical Examination Form

Step 1 of 2

Client Personal Details
Title*
Family Name / Surname*
Given Name(s)*
Gender*
Date of Birth*
DD slash MM slash YYYY
Current Age*
ID Number / Passport Number*
ID Number / Passport - Country of Issue*
Country
Email*
Telephone Number
Designation (If known)
Assignment Location (If known)
Weight (in Kilograms - example: 85)*
Height (in Meters - example: 1.65)*
BMI
As per OGUK requirements, a BMI greater than 30 may need a stress ecg as part of the examination - dependant on other medical issues identified

DETAILS OF COMPANY YOU WILL BE WORKING FOR : (IF KNOWN)
Name of Company
Contact Person Name
Contact Person Designation
Contact Person Email
Contact Tel Number
DETAILS OF RESPONSIBLE MEDICAL PERSON (TOP DOCTOR / MEDICAL ADVISOR) (IF KNOWN)
DETAILS OF RESPONSIBLE MEDICAL PERSON (TOP DOCTOR / MEDICAL ADVISOR) (IF KNOWN)
Declaration
Have you ever received a Restricted OGUK Medical Clearance Certificate?*
- Yes
- No
Please provide details for restricted OGUK Medical Clearance Certificate*
Have you even been refused an OGUK Medical Clearance Certificate?*
- Yes
- No
Please provide details for refused OGUK Medical Clearance Certificate*
General Notes and Comments:
CLIENT CHECKLIST
Please attach any relevant documents, namely : ID or Passport / Detailed Job Specifications / Relevant Medical Records / Previous Medical Certificate(s)
Please attach any relevant documents, namely ID or Passport / Detailed Job Specifications / Relevant Medical Records / Previous Medical Certificate(s)*
Drop files here or

Accepted file types: dcm, doc, docx, gif, jpg, pdf, png, ppt, pptx, rtf, txt, xls, xlsx, Max. file size: 5 MB, Max. files: 3.
Attachment/s must be less than 5mb and one of the following file types. .dcm, .doc, .docx, .gif, .jpg, .pdf, .png, .ppt, .pptx, .rtf, .txt, .xls, .xlsx
Declaration*
- Yes
- No
I, confirm that all the information captured above is correct, and an accurate representation of the facts provided. Together with this application form, I will forward a scanned copy of my valid passport and any communication received to oguk@traveldoccorp.com. In the event I do not provide the documentation required as noted above, I acknowledge that an appointment will NOT be arranged for this Oil & Gas UK Medical.

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CONTACT US

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+27 10 900 3013

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Oil & Gas UK Medical Examination Form

Step 1 of 2

Client Personal Details

DETAILS OF COMPANY YOU WILL BE WORKING FOR : (IF KNOWN)

DETAILS OF RESPONSIBLE MEDICAL PERSON (TOP DOCTOR / MEDICAL ADVISOR) (IF KNOWN)

Declaration

CLIENT CHECKLIST

ABOUT US

CONTACT US

+27 10 900 3013

Info@TravelDocCorp.com

8th Floor, Firestation Rosebank, 16 Baker Street, Cnr of Bath Avenue Rosebank, Johannesburg, South Africa

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