Referral Form - Click & KINNECT Portal

Company Details

Company Name

Candidate Details

Candidate Name*

First Last

Please provide the candidates legal name (as shown on their ID)

Candidate DOB*

Candidate Assigned Gender at Birth

Male
Female

Candidate Email*

Candidate Mobile*

Candidate Job Title*

Site*

Who should we send the results to?

Results Recipient - Name*

First Last

Job Title

Results Recipient - Email*

Results Recipient - Mobile*

Who should we send updates to?

Update Contact - Name*

First Last

Job Title

Update Contact - Mobile*

Update Contact - Email*

Appointment availability

Please provide a minimum of 5 dates and times that the candidate is available to attend their appointment.

What State does the Candidate require their appointment in?*

What town / city does the Candidate require their appointment in?*

Do you know the candidates availability for this appointment?*

Yes
No

Option 1 - Date*

e.g. 10/09/2023

Option 1 - Time*

Option 2 - Date*

e.g. 10/09/2023

Option 2 - Time*

Option 3 - Date*

e.g. 10/09/2023

Option 3 - Time*

Option 4 - Date*

e.g. 10/09/2023

Option 4 - Time*

Option 5 - Date*

e.g. 10/09/2023

Option 5 - Time*

KINNECT will contact the candidate to confirm their availability before scheduling their appointment

Are you purchasing any services that are related to health monitoring of the individual for exposure to any of the following hazardous items?*

HA Number

Please provide the HA number (from ResHealth) for each candidate

Has your organisation appointed KINNECT's Doctors as your AMA's?

Yes
No

Before we can schedule your requested services, you will need to complete this online form to appoint KINNECT's Doctors as your AMA.

Does your organisation have a Supervising Medical Practitioner for your Health Monitoring Program?*

Yes
No

Do you agree to appoint KINNECT's Doctors as your Supervising Medical Practitioner for your Health Monitoring Program?*

Yes
No

By agreeing to KINNECT being your Supervising Doctor they agree to the price scheduling for the relevant services. This may encompass: • Initial doctor review and advice (to give you advice including ‘what next’ if further costs might be involved) • Further doctor review and advice (after reviewing any additional information collated). • Individual’s case management compliant with any legislated requirements • Completion of any statutory forms.

Have you previously appointed KINNECT's Doctors as your Supervising Medical Practitioners?*

Yes
No

In order to appoint KINNECT's Doctors as your Supervising Medical Practitioner, you will need to complete a formal document.

Please download and complete the relevant form below based upon what service you require:

For Queensland Mines & Quarries Services: Complete this form
For Hazardous Exposure Medicals for all states (except WA): Complete this form
For Hazardous Exposure Medicals in WA: Complete this form

Please note, without the formal appointment of a Supervising Medical Practitioner, KINNECT is unable to schedule your requested service.

Upload Letter of Appointment for Supervising Medical Practitioner*

Max. file size: 80 MB.

Please upload your completed letter of appointment nominating KINNECT as your Supervising Medical Practitioners.

Please provide the details of your Supervising Medical Practitioner*

Name, Practice Name, Email, Phone

Is a Respiratory Fit Test required for this appointment?*

Yes
No

What mask type is used?

Full Face Respirator
Half Face Respirator
P2 / N95

Form submitted by

Myself
KINNECT

KINNECT Team Member*

Additional Information

Other additional information relating to this referral

Cancellation and Reschedule Fees

Before completing your order, please ensure that you have reviewed our Cancellation and Reschedule Policy and the below additional fees (which may apply), and agree to the terms and conditions.

Additional Fees

Further Medical Information ($185 + GST*)
If during the assessment process, a medical condition is identified, that requires further medical investigation and/or information from a treating doctor, KINNECT will contact the candidate and provide a referral letter to take to their treating doctor. Upon receiving this information back from, KINNECT’s Doctor will review the information and make the Fitness for Work Determination.
This fee ($185 + GST*) is to cover the cost of the referral letter, review of the additional information and a final fitness for work determination by the KINNECT Doctor.
To avoid a further medical review being required, KINNECT encourage the candidate to bring supporting documentation to their appointment should they have a medical / health condition and/or current injury. Supporting documentation may include a letter from your treating Doctor / Medical Specialist Pathology and/or Radiology Results.

Pre & Post Ventolin Spirometry (From $84 + GST*)
Should the spirometry demonstrate an abnormal finding, a pre-post Ventolin spirometry will be performed, ensuring the KINNECT Doctor has all the clinical information required to make a determination on the candidate's Fitness for Work. An additional fee of $84+ GST* will be applicable.

Medical Clearance (From $118 + GST*)
Should the initial functional assessment be ceased due to an identified health concern requiring medical clearance, KINNECT will issue the candidate a medical clearance letter for review and approval by their General Practitioner. Once approval is provided by their General Practitioner, they will be re-scheduled to complete the assessment. An additional fee of $118 + GST* will be applicable for functional assessments, while an additional $84 + GST* will be applicable for a spirometry or audiometry assessment.

*These fees may be higher if your appointment is scheduled at an Affiliate Partner clinic

I agree to the terms outlined within KINNECT's Cancellation and Reschedule Policy and the additional fees listed above (if required).*

Yes
No

Name

This field is for validation purposes and should be left unchanged.