Order form | Falck

Order number

Service

Choose when the first-day certificates should be issued

Day (8:00–10:00) Online / Doctor Nej

Day (08:00–10:00) – delivery and competence Physical visit / nurse

Delivery and competence Online visit / Doctor

Order type New Periodic check-up

Delivery Online Visit

Delivery Online Phone

After placing the order, a direct link to online appointment booking will be sent to the specified e-mail with the subject: "Kallelse - Välkommen till/Welcome to Falck"

Current work task(s): (1) Framföra fordon (2) Leda eller övervaka spårtrafik (3) Bedöma trafiksäkerheten hos fordon eller spåranläggningar (4) Bedriva trafik och arbete på spår enligt verksamhetsutövarens säkerhetsordning Fältet är obligatoriskt.

If there is an existing certificate, enter the expiry date of the certificate

Starting date

Ending date

Company

Orderer

Social security number (orderer)

Name (orderer)

E-mail (orderer)

Telephone (orderer)

Cost center

Enter the invoice reference as the invoice comment

Invoice comment

Employee

How many persons is the order for? One person A group

Attach the list of personal data in a separate document and upload it below. Use the template for group orders. (download template)

Swedish social security number Yes No

Choose employees + Add employee

Social security number (medarbetare)

Date of birth (employee)

Name (employee)

E-mail (employee)

Telephone (employee)

Risk assessment

Source of risk

Exposure

Work tasks

Attach any risk assessment below with file upload.

Other

Delivery city

Specify the immediate manager who will be the recipient of the first-day certificate…

Additional recipient of certificate or feedback No Yes

Name (alternative)

E-mail (alternative)

Telephone (alternative)

For supportive calls

Describe the work-related reasons ssues leading to this order and what changes you have observed in the employee.

Reason for supportive talk Stress Work situation Life situation Conflict Other Fältet är obligatoriskt.

Message

To attach multiple files: hold "ctrl" or "cmd" and select all the files you want to include in the order.

File upload

Send

All data is sent with a secure connection. In the next step, you can save a summary of the order as a pdf.

Drug test answers: If the service includes a drug test, a negative test result will be notified in email titled "Result of test " from noreply@Infosolution.se

If you want to discuss the activation or add sampling, first complete and submit the activation. Then order a Case Dialogue, Individual

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