Medical Clinic Registration Form

Medical clinic registration form

This form is used by medical clinic staff to add their medical clinic to the TruckSafe Member Access portal.

TruckSafe members in your area will know that your practice is familiar with carrying out Austroads Assessing Fitness to Drive (AFTD) commercial medicals, or can offer other medical services for the transport industry.

Please note the following:

The Fitness for Duty certificate used in the medical assessment can only be signed by a registered nurse, or general practitioner

The name of the person entered on this form will not be made publicly available

The email address entered on this form will not be made publicly available

This form is for the use of medical clinic staff only. It is not intended to be used by TruckSafe members to nominate a clinic

Once this form has been submitted we will contact the clinic for confirmation of submission.

Date(Required)

Your name(Required)

Your name will not be published or made available to the general public.

Name of your clinic(Required)

Address of your clinic(Required)

Clinic daytime contact number(Required)

This number will appear on our website and be available to the general public.

Clinic email address(Required)

This email address will be used by TruckSafe for health-related correspondence only with your clinic. It must be an address used by clinic staff. It will not be published or made available to the general public.

Services your clinic provides(Required)

General practice

Occupational medicine

Physiotherapy

Counselling

Other

A reminder that if you intend to conduct driver medicals it is a requirement of TruckSafe that an AFTD medical must be signed off by a general practitioner.

List other services provided(Required)

Privacy statement

We value your privacy. Information submitted via this form will only be used in accordance with our Privacy Policy.

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