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Comprehensive Assessments Group
Contact Us

Phone: 519-878-5839

Phone: 289-260-3210

Fax: 905-248-3360

Email: info@compmedgroup.ca

Referral Form - Medical / Legal
Referral Date:   (mm/dd/yyyy)
Claimant's Information
First Name:
Last Name:
Gender:
 
Date of Birth:   (mm/dd/yyyy)
Address 1:
Address 2:
City:
Province:
Postal Code:
Telephone:
Cell Phone:
Claim Number:
Date of Loss:   (mm/dd/yyyy)
Pre-injury Occupation:
Impairment:
Legal Representation
Lawyer's Name:
Law Clerk's Name:
Name of Law Firm:
Address:
City:
Province:
Postal Code:
Telephone:
Fax:
Email:
TORT Insurance Company:
AB Insurance Company:
Client
Name:
Telephone:
Email:
Type of Assessment
 
 
Additional Services To Be Arranged By CMAG
Interpreter Required?
  Language
Transportation Required?
   
Accomodation Required?
   
Special Instructions / Comments
  Multidisciplinary reports should be sent?
 
  I would like to be advised of appointment dates by:
 
  How would you like to be contacted:
 
 
Optional Referral Questions
  
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