Diary Direct – Online Booking Registration Form

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This is the Prime Diary Direct Registration Form for new clients.

Should you want more information or assistance,
please phone Prime on (08) 9242 0867

Section 1: Company Details

Company Name:

Postal Address:

Accounts Contact:

Accounts Email:

Accounts Phone:

Section 2: Medical Requirements

Medical Combinations:

Please detail the medical COMBINATIONS that you require by using the attached codes.

MA	Standard Medical Assesment
DAS	Drug and Alcohol Screen
INSTANT	Instant Drug and Alcohol Screen
AUD	Standard Audiometry
LBA	Workcover Audiometry
SPIRO	Spirometry (Lung Function Test)
MWHS	Mine Workers Health Surveillance
MUSC	Musculoskeletal Examination
MUSC+FIT	Musculoskeletal plus Fitness Test
BACKS	Back Strength and Flexibility
BIKE FITNESS	Aerobic Fitness Test (Bicycle)
ECG	Electrocardiograph
BLOODS	Blood Test (Pathology)
FAT	Fatigue Management Questionnaire
DRIVERS	Drivers Medical Examination (Commercial / Dangerous)
HUET	Huet Medical Clearance Certificate
UKOOA	Oil and Gas UK Medical
OWT	Offshore Travel and Work
ERT	Emergency Response Medical
RAIL CAT 1	Rail Category 1 Medical
RAIL CAT 2	Rail Category 2 Medical
RAIL CAT 3	Rail Category 3 Medical

Enter Medical Combinations below (1 combination per line, seperated with hyphen ( - ) bullet points)

Example:
- MA,DAS,LBA,SPIRO.
- MA,MUSC,DAS.
- etc.

Section 3 – Registration Details of Bookings

Booking officer/s details (please include title within company)

Booking Officer 1:

Booking Officer 1 Email:

Booking Officer 2:

Booking Officer 2 Email:

Booking Officer 3:

Booking Officer 3 Email:

Booking Officer 4:

Booking Officer 4 Email:

Booking Officer 5:

Booking Officer 5 Email:

Email address for results to be sent:

Answering yes to any of the below questions will make the fields mandatory and this information will be required at the time of booking or prior to the candidate arriving for their appointment.

Is a Purchase Order required for each booking? :

Is a Site Code required for each booking? :

Is a Cost Code (Department Code) required? :

Do you use your own Company Specific Paperwork? :

If yes, please attach paper work:

Section 4 - Details of Person completing this form

Full Name:

Title:

Email Address:

Phone:

I have read and understand the Terms and Conditions of use as set by Prime Health Group:

Read the full Terms and Conditions.