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About
Overview
Services
Our Services
Evaluators
Our Team
Locations
Referrals
Employer
Employer
Insurer
Lawyer
Contact
Careers
Careers
Employer Referral Form
Referral Information
Date
Time
AM
PM
Referral
New referral
Reschedule
Cancellation
Called in by
Employer
Assistant
Referring Company
Address
Address 2
City
Select
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
New option
New option
New option
Postal Code
Telephone
Fax
Cell
Email address
*
Employee Information
Employee Name
Gender
Male
Female
N/A
Last Day Worked
Reported injuries:
Date of Birth
Employee Address
Apartment Buzzer Code
Telephone
Legal Representative
Law Firm
Telephone
Fax
Interpreter
Required
Not Required
Language
Dialect
Transportation
Required
Not Required
Pick-up Address
Examination Required
Pre-Screen
Fitness to Work
Return to Work
STD
LTD
Other
Scheduling Preference
No
Yes
Report Deadline
Recommendations Required
No
Yes
Nature of Referral
File Review
File Review/Telephone Conference
Direct Assessment
Addendum
File Review
Future Care Cost
Other
Estimated File Size
Specialty Required
Chiropractic Evaluation
Psychology Evaluation
Neurology Evaluation
Psychiatry Evaluation
In-Home Occupational Therapy
Physiotherapy Evaluation
Job Site Analysis
Vocational Evaluation
Labour Market Survey
Nutritional Evaluation
Return to Work
Occupational Health Evaluation
Respirology Evaluation
Cardiology Evaluation
Neurophthalmology Evaluation
Orthopaedic Evaluation
Neuropsychology Evaluation
Physiatry Evaluation
1 day Functional Abilities Evaluation
Situational/Functional Occupational Therapy
2 day Functional Abilities Evaluation
Physical Demands Analysis
Transferable Skills Analysis
Social Worker Evaluation
Maxillofacial/Dental Evaluation
Ergonomic Evaluation
Ophthalmology Evaluation
Otolaryngology Evaluation (ENT)
Neurosurgery Evaluation
Other
Special Notes
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