Offshore Energies 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 OEUK Medical Clearance Certificate?*
- Yes
- No
Please provide details for restricted OEUK 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 oeuk@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 Offshore Energies UK Medical.

ABOUT US

Tailored to Business Travellers, Expatriates and Remotely Deployed Personnel. Focused on Corporate Travel Health. Specialised in Occupational Health. Multidisciplinary solutions to organised health challenges.

CONTACT US

(Not emergency contact details)

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+27 10 900 3013

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Info@TravelDocCorp.com

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Offshore Energies 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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