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REQUESTED
BY:
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Date of Referral:
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Adjuster:
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Email Address:
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Company:
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Address:
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Suite #:
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City:
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Province:
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Postal Code:
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Tel #:
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Ext:
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Fax #:
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Claim #:
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Policy #:
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Insurer
(if different from above):
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CLIENT INFORMATION
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Client's First Name:
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Address:
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Client's Last Name:
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City:
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Apt. #:
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Province:
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Postal Code:
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Home Tel #:
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Cell # if
applicable:
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Date of Birth :
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Date of Loss:
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Named Insured:
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Interpreter
Required/Language?
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Secondary Insured:
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SERVICES REQUESTED
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Section
44
Not
Section 44
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Worksite
Assessment
Functional
Capacity Evaluation
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In-Home
Occupational Therapy Assessment |
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In-Home
Occupational Therapy Re-Assessment |
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Housekeeping |
SPECIALTY
*Please indicate
Specialty Required:
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Form
1 (Assessment of Attendant Care) |
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Caregiving
- # of dependants? |
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Comment
of Personal Care Tasks but no Form 1
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Orthopaedic
Physiatry
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Return
to Work Plan
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Neurological
Psychology |
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Follow
through with IE recs.
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Other Specialty: |
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Independent
Medical Examination*
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EMPLOYER
INFORMATION (If Applicable)
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Company
Name:
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Address:
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Suite #:
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City:
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Postal Code:
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Province:
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Fax #:
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Telephone #:
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Title:
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Contact Name:
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Has Client Returned
to Work:
Yes
No
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Client’s
Occupation:
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INJURY INFORMATION |
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WAD
I
WAD
II |
Other :
1. |
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2. |
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WAD III
WAD
IV |
3. |
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TREATMENT INFORMATION–
i.e. physio, chiro, massage; etc. ? |
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1.
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3.
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2. |
4. |
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LEGAL REPRESENTATIVE INFORMATION |
Firm Name:
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Province:
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Contact Name:
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Postal Code:
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Address:
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Telephone
#:
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Suite #:
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Fax #:
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City:
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PHYSICIAN INFORMATION (OPTIONAL) |
(Family Physician):
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City:
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Name:
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Province:
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Clinic:
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Postal
Code:
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Address:
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Telephone
#:
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Suite #:
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Fax #:
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Any additional information that you
feel would be helpful to our assessment, can be included in the area below:
If you have any reports that you feel
would be helpful to our assessment, please send them along to us with
appropriate time to get to our firm prior to the assessment.
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