Send Us a Referral Referral Form Referral Date:* MM slash DD slash YYYY Claimant/Employee Information Date of Birth:* MM slash DD slash YYYY Name* Mr.Mrs.MissMs. Salutation First Last Job Title: Address Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Telephone:Cell Phone:Email: Enter Email Confirm Email Claim Number: Policy Number: Date of Loss: MM slash DD slash YYYY Referral Source Company:* Claim Type: Auto LTD/STD Legal Employer WSIB Third Party Referral Contact Name/Adjuster/Claims Processor:* Referral Address: Street Address Address Line 2 City AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon Province Postal Code Office Telephone Number:*Cell Phone:Legal Representation: Yes No Firm: Contact Name: Contact Phone:Type of Assessment(s): IME (please see selection of specialties below) File Review STD/LTD Med Legal : Defence Med Legal : Plaintiff Addiction (Medicine) Attendant Care Catastrophic Rating File Review Aviation Medical Income Replacement POEM (Post Offer Employment Medical) Other If Other:Specialties, please select from the list below OR check here and we will contact you to discuss your specific needs. Psychology Addiction Medicine Cardiology Cardiovascular Surgery Chiropractic Construction Engineering Dentistry Dermatology Emergency Medicine Endocrinology Ergonomics Forensic Psychiatry Gastroenterology General Practice General Surgery Geriatric Medicine Haematology Infectious Diseases Internal Medicine Kinesiology (Regulated) Naturopath Nephrology Neurocognitive Neurology Neuro-Ophthalmology Neuropsychiatry Neuropsychology Neurosurgery Obstetrics Gynecology Occupational Medicine Occupational Therapy Oncology Ophthalmology Optometry Oral & Maxillofacial Surgery Orthopaedic Surgery Otolaryngology (ENT) Paediatrics Pain Medicine Physiatry Physiotherapy Plastic Surgery Podiatry Psychometrist Psychovocational Radiology Registered Massage Registered Nurse Rehabilitation Counselling Respirology Rheumatology Social Worker Speech-Language Pathology Sports Medicine Thoracic Surgery Urology Vocational Medicine Other:If the specialty you require is not listed above, please enter it below.Interpreter Required? Yes No Language: Transportation Required? Yes No Ground Air Pickup Address: Accommodation Required? Yes No PhoneThis field is for validation purposes and should be left unchanged.