Online Referral

ASSESSMENTS REQUIRED

Chronic Pain

Dentistry & Oral Surgery

Ear, Nose & Throat

FAE / FCE

Neurological

Neurosurgery

Neuro-Opthalmology

Opthalmology

Orthopaedic

Physiatry

Plastic Surgery

Rheumatology

In-Home Assessments

Attendant Care Needs (Form 1)

Job Site Assessments (JSA/PDA)

OT Education and Intervention Sessions

Assistive Devices Program

Psychological

Psychiatric

Neuropsychological

Vocational Assessments

Transferable Skills (TSA)

Labour Market Analysis (LMS)

Speech Language

Social Worker

Psycho-vocational

Psycho-educational

Ergonomic

Personal Injury Assessment (MIG)

JSA

MRI

CT Scan

X Ray

CLAIMANT INFORMATION

Salutation

Mr.

Mrs.

Miss

Ms.

First Name

Last Name

Full Address

Phone (Home)

Phone (Cell)

Date of Birth

Referral Date

Date of Loss

INSURANCE INFORMATION

Insurance Company

Claim No.

Policy No.

Policy Holder

Adjusters Name

Full Address

Phone

Fax

TREATING PHYSICIAN

Name

Phone

REFERRAL PARTICULARS

Benefits Claimed

Housekeeping

Care Giving

Income Replacement

Yes

Interpreter Required

Language

Who Will Arrange

Vision

Claims Rep

Legal Rep

LEGAL INFORMATION

Represented By

Address

Contact

Phone

Fax

SPECIFIED BENEFITS/REFERRAL QUESTIONS

In your medical opinion, has the patient sustained a permanent and serious impairment of an important physical, mental or psychological function?

Given the injuries sustained by the patient and the subsequent impairments and limitations resulting from the car accident, in your medical opinion, is the patient capable of resuming pre-accident housekeeping activities?

In your medical opinion, will the patient require periodic medical and rehabilitation treatment in the future? If your answer is yes, please describe the nature of the medical treatment (e.g. periodic physiotherapy, chiropractic, massage therapy, psychological counseling, vocational counseling, marital and family counseling, gym membership, medication etc.).

In your medical opinion, has the patient suffered a complete inability to carry out a normal life as result of the accident? ?

In your medical opinion, has the patient suffered a complete inability to perform the essential tasks of his/her pre-accident occupation(s) at this time?

In your medical opinion, will the patient be capable to return to his/her pre-accident occupation?

In your medical opinion, what type of occupations will the patient be capable of given his/her limitations?

In your medical opinion, have the injuries and impairments sustained in the accident put the patient in a position whereby he/she is exposed to a loss of competitive advantage in the workplace and/or a loss of earning capacity?

In your medical opinion, has the patient sustained any permanent scarring as a result of the accident?

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