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Confidential Referral Form
Step
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Employer:
Referred by:
Contact Number:
Number
Email address:
To whom will the Medical Report be sent:
Name
Business Address:
PO number for invoicing:
*
Date and time of Appointment:
* Please note a non-attendance fee applies where 36 hours’ notice of cancellation has not been given.
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Time
:
Hours
Minutes
AM
PM
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:
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Year
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
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1982
1981
1980
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1978
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1972
1971
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1964
1963
1962
1961
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1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
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1936
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1934
1933
1932
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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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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