ActewAGL Appointment BookingInitial AppointmentsCompany Name*ACTEWAGL DistributionACTEWAGL retailEvoenergyIcon WaterCompany Contact DetailsName* First Last Email* Employee's DetailsName* First Last Date of BirthMobile Number*What is the nature of the injury?*Is this a pre-existing injury?*YesNoFurther detailsPlease provide any further details relating to the injury:Has the appointment already been booked?Has the appointment already been booked?*Yes - booked online via HotDocYes - booked via telephoneYes - booked in clinic at previous appointmentNo (please complete sections below)Appointment DetailsPlease provide the appointment date, time & clinicPreferred ClinicNorthsideSouthsideNo preferencePreferred Appointment TimeWeekday AMWeekday PMSaturdayNo PreferenceCAPTCHA Follow Up AppointmentsCompany Name*ACTEWAGL DistributionACTEWAGL RetailEvoenergyIcon WaterCompany contact detailsName* First Email* Employee's detailsName* First Name Last Name Date of BirthMobile Number*Has this injury been escalated to a Worker's Compensation claim?Has this injury been escalated to a Worker's Compensation Claim?*YesNoName of InsurerClaim NumberFurther detailsFurther detailsHas the appointment already been booked?Has the appointment already been booked?*Yes - booked online via HotDocYes - booked via telephone.Yes - booked in clinic at previous appointmentNo (please complete below sections)Appointment DetailsPreferred ClinicNorthsideSouthsideUnspecifiedPreferred appointment timeWeekday AMWeekday PMSaturdayNo preferenceCAPTCHAPhoneThis field is for validation purposes and should be left unchanged.