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LORAK
LORAK
Referral Form: Eastern Canada - Section B/BI
Referral Date:   (mm/dd/yyyy)
Insurer Information
*Company Name:
Address 1:
Address 2:
City: Province:
Postal Code:  
*Adjuster's First Name: *Adjuster's Last Name:
*Telephone: Cell or Other Phone:
Email: Fax:
Claimant Information
*First Name: *Last Name:
Gender:
*Date of Birth:
Address 1:
Address 2:
City: Province:
Postal Code: Email:
Telephone: Claimant Cell or Other Phone:
*Date of Loss: *Claim Number:
Diagnosis, Description of Injury, Special Requests
Legal Representation
Law Firm:
First Name: Last Name:
Address 1:
Address 2:
City: Province:
Postal Code:  
Telephone: Cell or Other Phone:
Email: Fax:
Assessments Type
Exam Type
 
Specialty Type (for IME & CE only)
 
Other:  
Diagnostics Imaging
 
Additional Services To Be Arranged By Lorak
The following services will be arranged by Lorak at no additional administrative cost.
Interpreter Required?
  Language
Transportation Required?
Pickup Address:
Accommodation Required?
  Instructions:
Would you like us to initiate direct contact with the claimant strictly to communicate the appointment details?
Comments / Special Instructions
Optional Referral Questions
  
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