Form

Clinic/Clinician Address
Clinic/Clinician Name
Clinic Manager

Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number
- Area Code Phone Number
Fax Number
- Area Code Phone Number
E-mail
Can we share your contact details with other OH professionals on our network should they need local support

Yes No
Clinic Information
Clinic type

Private Individual Clinic NHS Other
Consulting Rooms Available

Yes No
Opening Days

Mon Tue Wed Thu Fri Sat
Disable Access

Ramps Lifts Limited Access
Additional Services

Home Visits Available Office Visits Available Chaperone Service Available
Nearest Train Station
Nearest Parking
Number of Consulting Rooms
Clinical Qualifications Available
Please Select

Accredited specialist in Occupational Medicine AFOM MFOM FFOM Advanced DoccMed DoccMED OH Nurse Advisor (Specialist Register part 3) RGN Physio Therapist Counsellor CBT Counsellor
Other
Number of Clinical Staff
Name of Clinicans and Registration Numbers
List of official memberships and governing bodies
Clinic Services.
Please Select

Management Referrals Sickness Absence Consultations Pre-Placements Ill Health Retirement Counselling CBT Counselling Physiothrapy UK Offshore Medical Norwegian Offshore Medical Diving Medical HSE Approved Lead Medical HSE Approved Radiation Medical HSE Approved Asbestos Medical CAA Medical Medical Federal Aviation Administration Medical Maritime and Coastguard Agency Medical HAVS Medical Fork Lift Truck Medical DVLA Group 2 Medical Stress ECG Medical Chester or Other Step Test Medical Ergonomic Assessments Work Station Assessments Work Place Assessments OH Audits
Other
Clinic Resources
Please Select

ECG Audiometry Spirometry Phlebotomy D&A testing Identity Validated Blood Sampling Visual Screening (Titmus, Keystone or similar) DSE Work Station Assessment Travel Vaccines Yellow Fever Mobile Health Unit First Aid Training None of Above
Other
Core Services Price List
Management Referral
Pre-Placement
Counselling Session
Physio Session
OHN Hourly Rate
OHN Daily Rate
Cancellation Policy
Please upload a price list if available
How do we pay you

To ensure prompt payment we use BACS transfer straight into your account
Company Registration
VAT Number
Bank Name
Account Name
Account Number
Sort Code
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Clinic/Clinician Address

Clinic Information

Clinical Qualifications Available

Clinic Services.

Clinic Resources

Core Services Price List

How do we pay you