Employee pre-screening application

Name:

Surname:

ID Number:

Email Address:

Please select your sex:

Female Male Other

Please select your race:

African Indian Coloured White

Emergency contact name & surname:

Emergency contact number:

Past medical history:

Are you pregnant?

Yes No I don't know

Would you be interested in our backpack screening solution?

Yes No

Would you be interested in a virtual consultation in the comfort of your own home?

Yes No

Do you consent to us using pictures taken on the wellness day?

Yes No