Medical Assessment On-line Booking Form

FOR INSURERS, LAWYERS AND EMPLOYERS

Please fill the form as appropriate. If you have any questions or require further assistance, please call 08 9201 3300 Or Facsimile: 08 9201 2077
 

REFERRER DETAILS

Name* Title
Company*
Address City
State Postcode
Phone* Email*
Billing Details
Email address for report to be forward
 

CLAIMANT/EMPLOYEES DETAILS

Name* Title
Address City
State Postcode
Date of Birth* Phone
Email
Claim Number Purchase Order Number
Authorized By
 

APPOINTMENT DETAILS

Next Available Appointment  Yes No
Date Preferred Time Preferred*
Specialist Discipline Specialist Preferred
Security Required* Initial/Follow up Appointment*
Interpreter Required* Legally Represented*
Preferred Location SMS Confirmation Required
Comments
Note: Photo ID Required
 

ASSESSMENT DETAILS

 Yes - WA WorkCover Approved Impairment Assessment  Yes - Medico Legal Assessment
 Yes - Injury Management  Yes - Independent Medical Assessment
 Yes - Fitness for Work  Yes - ComCare
 Yes - Disability Assessment  Yes - Industry Specific/Statutory Medical Assessment
Comments
Attach Referral