Confidential Referral Form

Date and time of Appointment:
* Please note a non-attendance fee applies where 36 hours’ notice of cancellation has not been given.
Date
Time

: Hours

Minutes

AM/PM
Please select clinic:
- Naas
- Swords
Reason for referral: Please attach a job description.
Please provide any other relevant information or detail any specific questions you would like addressed?

Employee’s Name:
Employee Contact No.
Date of Birth:
Address:
Location and Department of Employee
Is the Employee conversant in English?
- Yes
- No
If No, please confirm a translator will be attending.*
- Confirmation
Confirmation of referral with employee:
I hereby confirm that I have discussed this referral and the reason for it with the employee and that he/she has agreed to attend the occupational health clinic.*
* Please note a non-attendance fee applies where 36 hours’ notice of cancellation has not been given.
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Employer: