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SENSES HEALTH and BEAUTY SPA Inc.

( Operating as PERFECT WELLNESS Centre )

SHERATON CENTRE TORONTO
123 Queen Street West, Unit C36
Toronto, ON M5H 3M9
Tel: (416) 901-8561
Fax: (647) 341-4675
Email: intake@PerfectWellness.ca
Referral Form - Injury Law Firm
Referral Date:   (mm/dd/yyyy)
Claimant's Information
First Name:
Last Name:
Gender:
 
Date of Birth:
     
Address:
Town/City:
Province:
Postal Code:
Telephone:
Work Phone:
Cell Phone:
Email:
Claim Number:
Date of Injury:
     
Disability Transportation:
 
Interpreter:
Law Firm
Name of Law Firm:
Address:
City:
Province:
Postal Code:
Lawyer's Name:
Law Clerk's Name:
Telephone:
Fax:
Email:
Treatments
 
  
 
Comments / Special Instructions
  
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