SAMSA Medica Form - Travel Doctor Corporate

Client Personal Details

Title*

Surname*

Name(s)*

Gender*

Designation / Job Description (If known)

Assignment Location (If known)

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Contact Number

Email*

Date of Birth*

Current Age*

ID Number / Passport Number*

ID Number / Passport - Country of Issue*

Country

Do you have any medical conditions that may prevent you from receiving a SAMSA medical certificate ?*

Yes
No

Details of medical conditions*

medical reports, including details of prescription medication, should be brought to the Consultation (the report should mention the reason for the medication, current status and management of the condition)

Information / Details*

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

PASSPORT*

Yes - Attached
No - Why not?

RELEVANT MEDICAL RECORDS*

Failure to supply these reports may result in the submission process being delayed

Yes - Attached
No - Why not?

PREVIOUS MEDICAL CERTIFICATE/S*

Yes - Attached
No - Why not?

Why not?

General Supporting Comments:

Declaration*

I, confirm that all the information captured above is correct, and an accurate representation of the facts provided. In the event I do not provide the documentation required as noted above, I acknowledge that an appointment will NOT be arranged for this SAMSA Medical.

Yes
No

Do you have any specific forms that need to be completed ?*

To note, each contracting company has various requirements for their candidates to comply with, and these will be listed on the forms that need to be completed.

Yes
No

If YES, please attach these forms here

Max. file size: 64 MB.

SAMSA Medical Examination Form

Client Personal Details

CLIENT CHECKLIST