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Referral Date:

(mm/dd/yyyy)

Law Firm Information
*Law Firm:
	Plaintiff Counsel Defense Counsel
Address 1:
Address 2:
City:		Province:	ABBCMBNBNFNSNTNUONPEQCSKYT
Postal Code:
*Lawyer's First Name:		*Lawyer's Last Name:
Assistant's First Name:		Assistant's Last Name:
*Telephone:		Cell or Other Phone:
Email:		Fax:
Date of Injury:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember	File/Reference Number:
MVA:	Yes No	If not MVA Please Indicate:

Examinee Information
*First Name:		*Last Name:
Gender:	Male Female	Date of Birth:	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Insurance Company Information
Tort Insurer:
Accident Benefits Insurer:

File Description
Diagnosis:
Size and delivery method for medical documents
Size In Inches:		Delivery Method:	CourierFaxMailSecureDocsOther

Requested Assessments
Physical Assessments	Medical File Review In Person Examination
Anesthesiology Gastroenterology Neuro-Opthamology Orthopedic Surgery Rheumatology Audiology General Surgery Neurology Otolaryngology (ENT) Social Worker Cardiology General Practitioner Neurosurgery Pediatrics Speech Language Pathology Chiropractic Hematology Occupational Medicine Physiatry Thoracic Surgery Dentistry Infectious Disease Oncology Physiotherapy Urology Dermatology Internal Medicine Ophthalmology Plastic Surgery Vascular Surgery Endocrinology Immunology Oral Surgery Respirology
Other:
Psychological / Psychiatric Assessments
Neuropsychology Forensic Psychiatric Workplace Assessment Psychiatry Psychology
Functional & Vocational Assessments
Job Site Analysis (JSA/PDA) Functional Abilities Evaluation (FAE/FCE) Ergonomic Assessment Other:
Vocational Vocation with TSA & LMS Psychovocational Other:
Diagnostics Imaging
Bone Scan CT Scan MRI X-ray

Additional Services To Be Arranged By A.R.S.
The following services will be arranged by A.R.S. at no additional administrative cost.
Interpreter Required?	Yes No		Language
Transportation Required?	Yes No	Ground Air	Pickup Address:
Accommodation Required?	Yes No		Instructions:
Would you like A.R.S. to initiate direct contact with the claimant strictly to communicate the appointment details?			Phone Letter Phone or Letter No Direct Contact

Comments / Special Instructions

Optional Referral Questions

Please indicate which questions you would like the assessor(s) to answer in their medical report after the assessment has taken place.

Within the scope of your medical discipline, what is examinee’s primary & secondary diagnosis Within the scope of your medical discipline, what is examinee’s prognosis? Within the scope of your medical discipline, what are the present medicals barriers to the examinee’s recovery, if any? Within the scope of your medical discipline, is the examinee able to resume full-time work at this time? If not, when will the examinee be capable of doing so? Within the scope of your medical discipline, what are the examinees present physical restrictions, if any? And how are those restrictions being addressed by way of treatment? Within the scope of your medical discipline, is the examinee capable of graduated return to work at this time? If not, when will the examinee be able to do so? If applicable, please detail the graduated return to work plan. Within the scope of your medical discipline, does the examinee require medication? Within the scope of your medical discipline, does the examinee require physiotherapy treatments of any kind? If so, what is the frequency and duration recommended? Within the scope of your medical discipline, can the examinees reported symptoms be supported by the existence of objective clinical pathology? Within the scope of your medical discipline, please comment on the reasonableness of the examinees current treatment as to benefit & therapeutic value. Within the scope of your medical discipline, does the premorbid medical history suggest that the examinee would have exhibited physical restrictions that would have limited his/her functional abilities prior to your examination? Within the scope of your medical discipline, do you suspect any abnormal underlying pathology requiring further medical investigation? If yes, please explain. Within the scope of your medical discipline, has maximum medical recovery (MMR) been achieved? If not please indicate an anticipated time frame. If MMR has been reached, please provide an explanation for concluding that the condition is stable and stationary and unlikely to change. Within the scope of your medical discipline, do you recommend any further treatment / assistive devices to reduce and/or eliminate these restrictions? If so, please indicate type & frequency. Within the scope of your medical discipline, are there any further considerations or recommendations you might suggest in order to enhance this individual’s return to maximum functioning? Within the scope of your medical discipline, does the examinee require transportation services (e.g. taxi) to attend medical appointments? Within the scope of your medical discipline, do you concur with the medical diagnosis/impairment descriptions that have been provided to date? Within the scope of your medical discipline, were there any pre-existing psychological conditions? If not, please explain. Within the scope of your medical discipline, what is the present psychological status with the resulting DSM IV code? Is this permanent or temporary? Within the scope of your medical discipline, do your objective findings indicate any cognitive deficits as a result of the accident? If yes, please indicate the estimated duration of impairment. Within the scope of your medical discipline, are the examinees cognitive abilities intact and is there normal thought process present? Please comment. Within the scope of your medical discipline, do you suspect functional overlay requiring psychological attention or assessment? Within the scope of your medical discipline, do you consider the rate of progress to be satisfactory in this case? Within the scope of your medical discipline, is further medical investigation required? If so, what investigations and why? Within the scope of your medical discipline, has the examinee been following the recommended treatment protocol prior to your examination? Within the scope of your medical discipline, is anything impeding further or a more timely recovery?

Additional Questions: