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Dynamic Functional Solutions Inc. (DFSI)
105 - 120 Traders Blvd. East
Mississauga, Ontario L4Z 2H7
Toll-Free: 1(877) 897-5515
Referral Form
Referral Date:
(mm/dd/yyyy)
Referral Source
Adjuster/Case Manager First Name:
Adjuster/Case Manager Last Name:
Insurance Company:
Address:
City:
Province:
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
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MS
MO
MT
NE
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NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Postal Code:
Telephone:
Fax:
Email:
Claimant Information
Claimant First Name:
Claimant Last Name:
Date of Birth:
Gender:
Male
Female
Address:
City:
Province:
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
Postal Code:
Telephone:
Alternate Phone:
Claimant Email Address:
Date of Loss/Date Last Worked:
Claim Number:
Are there any details for this claimant?
Legal Representation (if applicable)
Law Firm:
Lawyer First Name:
Lawyer Last Name:
Address:
City:
Province:
AB
BC
MB
NB
NF
NS
NT
NU
ON
PE
QC
SK
YT
Postal Code:
Telephone:
Fax:
Email:
Requested Assessments
For an extensive list of all the assessment services we offer please vistit our
Services
section in our website. If you do not see a service listed, please fill-in the "Other" field.
Assessment Type
In-Person
Paper Review
Virtual
Physical Health
Cardiology
Chiropractic
General Practice
Massage Therapy
Neurology
Occupational Therapy
Oral and Maxillofacial Surgery
Orthopaedic Surgery
Otolaryngology
Plastic Surgery
Physical Medicine and Rehabilitation
Physiotherapy
Rheumatology
Mental Health
Neuropsychology
Psychiatry
Psychology
Vocational Health
Ergonomic Assessment
Functional Abilities Evaluation
Labour Market Survey
Psychovocational Evaluation
Transferable Skills Analysis
Vocational Testing
Work-Site Assessment
Other
Claim Type
MIG Determination
Med/Rehab
CAT Determination
Income Replacement Benefits
Post-104 Income Replacement
House Keeping/Home Maintenance
Attendant Care
Caregiver Benefits
Non-Earner Benefits
Long Term Disability (LTD)
Short Term Disability (STD)
Absence Management Solutions (AMS)
Accommodation Assessment
Medicolegal
Additional Services To Be Arranged By Dynamic Functional Solutions
Interpreter Required?
Yes
No
Language
Transportation Required?
Yes
No
Do you have specific instructions for the claimant (example: preferred booking timeframe)?
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