Workplace Rehabilitation Referral Form

To submit a referral please complete the form below and we will be in touch. Please complete at least the ‘Referral Source’ fields so that we can contact you in relation to the referral.

Referral Source

Name (Required)

Telephone (Required)

Company (Required)

Email (Required)

Attach Documents

Please leave this field empty.

Service

Injured Worker

Worker Name

Telephone

Address

Date of Birth

Date of Injury

Job Title / Occupation

Nature of Injury

Interpreter Needed

Language

Employer

Employer Name

Worksite Location

Address

Supervisor / Return to Work Coordinator

Telephone

Fax

Employment Status

Insurer

Insurer Name

IMA

Case Manager

Telephone

Fax

Address

Claim Number

Liability Accepted

Treating Doctor / Other

Name

Telephone

Address

Fax

Workplace Rehabilitation Referral Form

Referral Source

Attach Documents

Service

Injured Worker

Employer

Insurer

Treating Doctor / Other

Other Relevant Information

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