Online Consent Form

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The Occupational Health assessment that you are about to receive is being carried out at the request of your employer so that OH advice can be provided on how your health affects your ability to work. The General Medical Council recommends that you have an opportunity to confirm that you understand the purpose of the assessment; consent to being assessed by the Occupational Health Advisor or Physician; and consent to a report based on the assessment being supplied to your employer. In accordance with the GMC council, FOM guidance, NMC and Data Protection Act 1998 and Access to Medical Reports Act 1988.

Section 1: Patient Details

Title (Mr/Mrs/Miss/Ms/Other)

Surname

Forename(s)

Your Date of Birth

Your Employer

Home Address

Tel No

Email

Section 2: Patient Consent

Please read and sign below.

SECTION A

Consent to assessment

YesNo

The nature and purpose of the assessment have been explained to me. I understand that the assessment may include a physical examination.
I agree to undergo this assessment for the purposes of a report being prepared for my employer by the Doctor or Nurse. I understand that the report will comprise Occupational Health recommendations about my fitness for work and likely timescales and will only include limited, relevant information about my medical conditions. I understand that I have the right to access this report and any other occupational reports related to me.

Signature (type name)

Date

SECTION B

I give my consent for an Occupational Health report to be supplied in confidence to my employer. I understand that the report will only include limited, relevant information about my medical conditions.

I understand by ticking the above option of no consent that no fitness report will be issued to my employer other than a statement that the appointment has been attended and that there has been no consent to the release of a report to my employer. I understand that the hand written clinical record from the consultation will be kept within my Occupational Health file but no further action will be taken and I accept the potential risks to my physical and/or psychological health as a result of this non-disclosure of information.

If you wish to have access to the OH report, it will be sent to you by email or to your home address.

Signature (type name)

Date