Online Referral Form

Referring Company Information Contact Name Company Telephone Number Fax Number E-Mail Address Services Required Ergonomic Work Site Assessment Functional Capacities Evaluation Independent Medical Examination/Insurer's Examination Job Site Analysis/Physical Demands Analysis Neuropsycho-vocational Assessment O.T. In-Home Assessment with Form 1? Yes No Paper File Review Psycho-vocational Assessment Vocational Transferable Skills Analysis with Labour Market Survey? Yes No Diagnostic Testing MRI CAT Scan Doppler Evaluation Bone Scan Speciality/Specialties Addiction Medicine Allergy and Immunology Cardiology Cardiovascular Surgery Chiropractic Dental and Oral Surgery Dentistry (TMJ) Emergency Medicine Endocrinology Ergonomics General Practice Geriatric Medicine Haematology Infectious Diseases Internal Medicine Kinesiology Nephrology Neurology Neuro-Ophthalmology Neuro-Psychiatry Neuro-Psychology Neurosurgery Obstetrics / Gynaecology Occupational Medicine Oncology Orthopaedic Ophthalmology Oral and Maxillofacial Surgery Otolaryngology (ENT) Paediatric Pain Medicine Physiatry Physiotherapy Plastic Surgery Podiatry Psychiatry Psychology Psychovocational Registered Massage Therapy Respirology Rheumatology Thoracic Surgery Vocational Assessments Other Please Specify Other Services To Be Arranged Translator Language Required Transportation Accommodation Would you like us to forward a "notification of appointment" letter to claimant and or legal representative? Claimant Information Last Name First Name Telephone Number Mailing Address City Province Please Select Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code Date of Loss Date of Birth Policy / Claim Number When is the appointment required? Claimant's Sex Male Female Type of Claim Type of Benefit Legal Representative Information Representative Name Firm Name Mailing Address City Province Please Select Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Postal Code Telephone Number Fax Number