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LORAK
LORAK
Referral Form: Medical Legal
Referral Date:   (mm/dd/yyyy)
Law Firm Information
*Law Firm:
 
 
Address 1:
Address 2:
City: Province:
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: File/Reference Number:
MVA:
If not MVA Please Indicate:
Examinee Information
*First Name: *Last Name:
Gender:
Date of Birth:
Insurance Company Information
Tort Insurer:
Accident Benefits Insurer:
File Description
Diagnosis:
Size and delivery method for medical documents
Size In Inches: Delivery Method:
Requested Assessments
Physical Assessments
 
 
Other:  
Psychological / Psychiatric Assessments
Functional & Vocational Assessments
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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