ON-LINE REFERRAL FORM
Location:
 Ottawa
 
 Kitchener
 
 London
 
 Toronto

REFERRAL SOURCE INFORMATION:
Name:
Company:
Address:
Phone:
Fax:
E-mail:
Claim/Policy/File #:

CLAIMANT / INSURED INFORMATION:
May we contact the Claimant / Insured? 


Yes No
Name:
Address:
City:
Province:
Postal Code:
Phone:
 
Date of Loss/Disability:
Month:
 
Day:
 
Year:

Status at date of loss:


Employed
 


Caregiver
 


Student
 


Unemployed
 


Other

If 'Other' please specify above.
Language Spoken:


English
 


French
 


Other

If 'Other' please specify above.
Interpretation Required: 


Yes No
Transportation Required: 


Yes No


Legal Representation:


Yes No
If Yes is selected then please fill out the information below:
Legal Representation:
Firm:
Phone:
Fax:

HOW CAN WE HELP YOU?
Independent Medical Examination:

If 'Other' please specify above.


If you require multi-disciplinary assessments please specify above.
Functional Capacity Evaluation:

Home-Site Assessment

Physical Demands Analysis:
Company Name:
Address:
City:
Province:
Postal Code:
Phone:
Fax:
Contact Person/Supervisor:
Claimant / Insured’s Position:

Vocational Assessment

Diagnostic Imaging:

If 'Other' please specify above.
Other Service Required

Preferred dates of booking:


2-3 weeks
 


4-6 weeks
 


Other

If 'Other' please specify above.
Nature of injury and anything else we should know.


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