Please note: All fields marked with an * are mandatory. If not, we will be unable to process your request.

Claim Number: 
Date Of Referral
Day  Month  Year  *
Referral Source
Name:
  *
eMail:
  *
Adjusters Name:
  *
Title:
  *
Company:
  *
Phone:
  *  Ext.
Fax:
  *
Address:
  *
City:
  *
Province:
  *
Postal Code:
  *
Client Information
Salutation:
Last Name:
  *
First Name:
  *
Address:
  *
City:
  *
Province:
  *
Postal Code:
  *
Home Phone:
  *
Other Phone:
Date Of Birth:
D  M  YR  
Date Of Injury:
D  M  YR  *
Medical Information
Injuries
(Please include all details):
Treating Physician:
Address:
City:
Postal Code:
Province:
Phone:
Fax:
Legal Information
Legal Representative:
Title:
Company:
Phone:
Fax:
Address:
City:
Province:
Postal Code:
Employment Information
Employer Name:
Contact:
Address:
City:
Province:
Postal Code:
Job Title/Occupation:
Phone:
Fax:
Independent Examinations - Assessment Type
 Cardiology
 Cardiovascular Surgery
 Chiropractic
 Dental/Oral
 ENT
 FamilyMedicine
 Functional(FAE/FCE)
 General Surgery
 Geriatric
 Hepatology
 Infectious Diseases
 Internal Medicine
 Massage Therapy
 Medicine
 Neuro-Ophthamology
 Neurological
 Neuropsychiatric
 Neuropsychological
 Neurosurgery
 Occupational Therapy
 Oncology
 Ophthamology
 Orthopaedic
 Physiatry
 Physiotherapy
 Psychiatric
 Psychological
 Psychological/Children
 Psychological/Geriatric
 Respirology
 Rheumatology
 Sleep Disorders
 Social Worker
 Urology
 Ergonomic
 Labour Market Analyses
 Physical Demands Analyses
 Psycho-Educational
 Psycho-Vocational
 Transferable Skills
 Vocational
 In-Home Assessment
 Job Site Analysis
Other Assessments - Please Specify
 Diagnostic Testing (MRI's etc.)
 Executive Summary Of Multi-Disciplinary Assessment Opinions
 Other
 
Other Options
Transportation:
 Yes
 No
 To Be Determined
Interpreter Required:
 Yes
 No
Language:
Benefits Claimed
 Income Replacement Benefits
 Caregiver Benefits
 Attendant Care Benefits
 Non Earner Benefits
 Housekeeping/Maintenance Benefits
 Medical/Rehabilitation Benefits
Optional Referral Questions
Check All That Apply
  1.
Please provide your diagnosis of any injury sustained as a direct result of the motor vehicle accident.
 2.
Please provide your prognosis for any injury sustained as a direct result of the motor vehicle accident.
 3.
Does the client currently have any functional limitations and/or physical restriction?
 4.
Does the client suffer an inability to return to the normal tasks of his/her employment?
 5.
If yes to #4, please provide an anticipated return to work date.
 6.
Does the client currently require any prescription or over the counter medication a direct result of injuries sustained in the accident?
 7.
Does the client suffer from any pre-existing medical condition? Has this been exacerbated as a result of the accident? If so, to what extent? If present, how might this condition affect the recovery from injuries sustained in the accident?
 8.
Has the client achieved maximum medical recovery (MMR)? If not please provide your opinion as to when this may occur.
 9.
Does the Client suffer from a substantial inability to perform the essential tasks of the daily living as a direct result of injuries sustained in the accident?
Additional Questions   

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