Medwise Confidential Audiovisual Consultation Registration & Consent

Step 1 of 3

Confidential Audiovisual Consultation Registration & Consent
Name*
Date of Birth
Age:
Personal Public Service Number:

Only if required for DEASP certification
Address:
Telephone contact: (mobile/home)*
Email*
Employer:
Date of recruitment:
Date last at work:
Occupation:
GP name & address:
Specialists name & address:

Audio-visual Teleconference Occupational Health Assessment:
Purpose:

Occupational health assessment by telephone call /video-call (tele-consult) takes place when the employee is unable to attend the Medwise clinic in person. Following the tele-consult, the doctor or nurse will issue a report to your employer outlining the impact of your health problems on your fitness for work. The report will give a likely return to work date and outline if there are any adjustments necessary to your work environment to accommodate your health needs and facilitate your return to work. The consultation will not be recorded.

Process:

The Medwise nurse or doctor will telephone / Skype / Zoom / Team call you at an agreed time to ask questions about your current medical problems, treatment and progress with recovery. The tele-consult will last about 20-40 minutes. Please ensure that you have access to Skype, a microphone and a speaker. Please ensure that you can take the call in a private room without distractions or interruptions. Please have photo ID to show to the doctor / nurse.

Please complete the registration form and consent on the next page and return to Medwise by post or secure email 2 days prior to the consultation. You are welcome to send a letter / secure email from your own doctor outlining your health issues in advance of the tele-consult.

Consent and Data Protection:

The tele-consult cannot take place unless you sign consent to engage with the process and agree to data protection issues (see 1. & 2. of the consent form overleaf).

The doctor or nurse cannot disclose your medical details to the employer unless you sign the consent to allow disclosure (see 3. of the consent form overleaf). The doctor or nurse cannot contact your treating doctors unless you sign the consent to allow Doctor-Doctor communication (see 4. of the consent form overleaf). You may prefer to defer consent for disclosure and / or doctor to doctor communication to a later stage or not at all.

The occupational health report will be available to you from the employer under the terms of the Data Protection Act. If you have any issues with engaging with the teleconferencing process, please discuss with your manager in advance of the appointment.

Teleconference Occupational Health Consultation Consent Form

1. Consent to engage in a teleconference occupational health assessment:

By signing below, I give my consent to engage in a teleconference occupational health assessment with a doctor or nurse from Medwise at the request of my employer for the purposes of preparing an occupational health report outlining my fitness for work.

2. Consent to retaining personal health data:

By signing below, I consent to Medwise retaining my personal health data as outlined and forwarding to The Department of Employment and Social Protection for certification purposes and to The HSE for testing of infection if required.

The types of personal data, which we process for occupational health purposes, which are covered by the General Data Protection Regulations 2018, include name, residential address, data concerning health, medical information, insurance details, occupational information, birth date.

We will safeguard your personal data to ensure it remains confidential and will only handle your personal data in accordance with the terms contained in our Privacy Notice (available on request) and applicable data protection law.

We will retain your medical records on an ongoing basis, for as long as we have a relationship with you, and in order for us to: (a) comply with our legal records retention obligations; (b) inform a diagnosis of a latent condition, ensure your health and safety and protect your vital interests; (c) defend or bring legal claims; and/or (d) address complaints regarding our services.

We will delete your personal data once it is no longer required for these purposes. You may withdraw your consent at any time in which case we will delete your data unless we are otherwise permitted to keep your data for statutory or compliance.
1, 2 Signed:*
Date*
MM slash DD slash YYYY
3. Consent to disclose medical details to the employer:

I give my consent to Dr Deirdre Gleeson or another Medwise Doctor / Carol Kennedy or another Medwise Nurse to disclose to the above the nature of my medical condition and as to how it affects my ability to work.

4. Consent for doctor to doctor communication:

I give my consent to my treating doctors and or healthcare providers to communicate, liaise and disclose my medical details to Dr Deirdre Gleeson or another Medwise Doctor / Carol Kennedy or another Medwise Nurse, in order to facilitate assessment of my fitness for work.
3, 4 Signed:*
Date*
MM slash DD slash YYYY
Please provide the names and doses of your current Medication: (use overleaf if required)

MedWise occupational health physicians provide expert advice to HR, Health and Safety and Management.

Naas Clinic

Unit 32, Naas Town Centre,
Dublin Road, Naas,
Co. Kildare
W91 R230

Swords Clinic

First Floor, Chamber Building
North Street, Swords
Co. Dublin
K67 A3H7

Medwise Confidential Audiovisual Consultation Registration & Consent

Step 1 of 3

Confidential Audiovisual Consultation Registration & Consent

Audio-visual Teleconference Occupational Health Assessment:

Please answer the following lifestyle questions: