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 Western Australia: Download Letter of Appointment Template
For Hazardous Exposure Medicals for all other States: Download Letter of Appointment Template

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

Cancelation and Reschedule Fees

Before completing your order, we recommend reviewing our cancelation and reschedule policy. Please note, additional fees, as outlined within the policy, may apply if you cancel or reschedule your appointment after placing your order.

I agree to the terms outlined within KINNECT's Cancellation and Reschedule Policy.*

Yes
No

Name

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