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Make a Referral

Please fill in and submit the form below. Optionally, you can print out the pdf form and fax or mail it to one of our offices.

Treatment Referral Form – PDF

Injury Treatment Referral Form – PDF Writable

GP Referral Form – PDF Writable

Worker Details
Surname*
Title*
First name*
Address*
Email*
Home Phone
Work Phone
Date of Birth
Interpreter Required
- Yes
- No
Language
Occupation
Employer
Company
RTW Coordinator
Supervisor/Manager
Address
Phone
Fax
Email
Insurer
Company
Contact
Claim Number
Address
Phone
Fax
Email
Injury Details
Date of Injury
Injury
Treating Doctor
Doctor's Name
Doctor's Phone
Doctor's Fax
Doctor's Address
Service(s) Required
Same Employer Rehabilitation
- RTW SE Case Management
- Functional Assessment
- Workplace Assessment
- Ergonomic Assessment
- Combination Functional / Workplace Assessment
- Combination Functional Assessment GP Case Conference
- Combination Workplace Assessment GP Case Conference
- ADL Assessment
- Initial Needs Assessment (Comcare only)
- Early Interventions Assessment – Workplace Assessment / Initial Meeting / GP Case Conference
New Employer Rehabilitation Services
- Vocational Assessment Only
- Vocational Rehabilitation
- Transferrable Skills Analysis
- Activait Complex Case Rehabilitation
Medico-Legal Services
- Earnings Capacity Evaluation
- S40 – Vocational Assessment
- S40 – Vocational / Functional Assessment
- S40 – Vocational / IMC Assessment
- Pre Liability Psychological Assessment
Medical Assessment / Treatment Services
- Optimise Physiotherapy Functional Assessment / Treatment
- Optimise Psychology Assessment / Treatment
- Medical Assessment (Sports Physician)
- Medical Advisory Board Assessment (Physio / Psychologist / Sports Physician)
Corporate Health Services
- Pre Employment Functional Assessment
- Pre Employment Psychological Assessment
- Fitness For Work Assessment
- Onsite Physiotherapy Services
- Health and wellbing Services
Training and Consulting Services*
- OHS Training and Consulting Servcies
- Injury Management Training and Consulting Servcies
* Injury Treatment will contact you to dicuss in depth your requirements.
Comments
Comments
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Workplace Rehabilitation
Vocational Rehabilitation
- Integrait Vocational Rehabilitation
- Integrait Job Seeking Services
Training and Consultancy
- Injury Management Training and Consulting Services
  - Physical Services
  - Psychological Services
- Injury Management Systems Consulting and Development
Medical and Allied Health
Corporate Health and Wellbeing
Medico-Legal
Complex Claims
- Injury Treatment Tail Management Services

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