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3 Director Court, Suite 104
Woodbridge, ON L4L 4S5
Tel: 905-850-1155
Online Referral Form
Referral Date:   (mm/dd/yyyy)
Claimant/Employee Information
Salutation: Date of Birth:
*First Name: *Last Name:
Job Title:
Address 1:
Address 2:
City: Province:
Postal Code:  
Telephone: Cell Phone:
Fax: Email:
Claim Number: Policy Number:
Date of Loss:
Referral Source
*Company Name:
Claim Type:
*Referral Contact:
Assistant Contact:
Address 1:
Address 2:
City: Province:
Postal Code:  
*Telephone: Cell Phone:
Email: Fax:
Insurance Company:
Insured's Name:
Policy Number:
Employer Information (if applicable)
Company Name:
Address 1:
Address 2:
City: Province:
Postal Code:  
Telephone: Cell Phone:
Email: Fax:
Legal Information (if applicable)
Firm Name:
Address 1:
Address 2:
City: Province:
Postal Code:  
Telephone: Cell Phone:
Email: Fax:
Type of Assessment
 
 
Other:
Reason for Assessment
 
Dated:
Dated:
Dated:
Other:
Services Requested
 
 
Other:
Additional Services To Be Arranged By CORE IHR
Interpreter Required?
  Language
Transportation Required?
   
Accommodation Required?
  Instructions:
Communication Instructions
Assessment Confirmation To Be Sent By:
 
Claimant Notice of Assessment Letter:
Claimant Notice of Assessment Phone Call:  
Medical File To Be Received By:
 
Comments / Special Instructions
Optional Referral Questions
  
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