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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:
If not MVA Please Indicate:
Examinee Information
*First Name: *Last Name:
Date of Birth:
Insurance Company Information
Tort Insurer:
Accident Benefits Insurer:
File Description
Size and delivery method for medical documents
Size In Inches: Delivery Method:
Requested Assessments
Physical Assessments
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?
Transportation Required?
Pickup Address:
Accommodation Required?
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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