On-site Consent Form

Your Full Name*
On-site Reference*
Employer/Training Provider/Company Name*
Email Address*
Contact Telephone*
Date of Birth*
DD slash MM slash YYYY
CONSENT FOR CONSULTATIONS AND REPORTS

I, the Candidate, confirm that I have been informed by my employer/training provider or company requesting a certificate of fitness, and I agree to take part in this medical.

I understand that my personal data will be shared with Ryminster Medical Services Ltd (T/A D4Drivers), and my employer/training or company requesting the medical assessment provider.

I understand that any report will include appropriate information in relation to my current and potential future fitness to drive, such as:

– Copies of medical notes/forms

– Fitness outcome (e.g. pass/fail)

– Drug/alcohol screening results (if applicable)

– Recommendations

A report will be sent following the assessment to your employer/training provider or company requesting the medical assessment.

By signing below, I understand that in agreeing to this medical assessment, my personal data will be processed in accordance with this form and the Privacy Notice which can be accessed via our website on www.d4drivers.uk
If you wish to receive a copy of the report, please tick the below
- I wish to receive a copy of the report
Signature (Please write your full name in CAPS LOCK)*
Date of Consent Signed*
DD slash MM slash YYYY