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Our Advantage
Specialty Assessment
Our Process
Contact
Referral Form
COVID-19 Update
info@excelmed.ca
CALL US TODAY:
(647) 349-1920
About Us
Our Services
Our Advantage
Specialty Assessment
Our Process
Contact
Referral Form
REFERRAL FORM
Patient Information
Download Referral Form
Date of Loss:
(Required)
Last Name:
First Name:
(Required)
Middle Name:
Sex:
(Required)
Male
Female
Birth Date:
(Required)
DD slash MM slash YYYY
Home Phone #:
Cell Phone:
(Required)
Street Address:
(Required)
Apt. #:
(Required)
City:
(Required)
Province:
(Required)
Postal Code:
(Required)
Insurance Information
Company Name:
(Required)
Policy:
(Required)
Claim:
(Required)
Date of Loss:
(Required)
MM slash DD slash YYYY
Adjuster Name:
(Required)
Telephone:
(Required)
Fax:
Legal Representative
Company Name:
(Required)
Lawyer:
(Required)
Clerk/Assistant:
(Required)
Telephone:
Fax:
Email:
(Required)
Referral information
Name:
(Required)
Telephone:
Fax:
Email:
(Required)
Interpreter required:
(Required)
Yes
No
What language
Check Box
AB:
TORT:
Medical Brief:
(Required)
Faxed
Mailed
Couriered
Questions to be addressed:
(Required)
Yes
No
Report due by:
Services check box
(Required)
Case Management (OT, RN)
Hospital Discharge Planning
Home Safety
Home Accessibility
Attendant Care, Form 1
Home Medical Equipment
Home Modifications
Vehicle Modification
Job site/Ergonomic
Functional Abilities Evaluation (FAE)
Physical Demand Analysis
EMG/NCS
MRI
CT Scan
Sleep Disorder Study
Rehabilitation Support Worker (RSW)
Nursing
Personal Care (PSW)
Companion/Housekeeping
Chronic Pain Management Program
Driving Integration Program
Vocational Reintegration Program
Work Hardening Program
Weight Loss Program
Expert File Review
Other
Catastrophic Impairment
Chronic Pain
Dental/TMJ
Future Care Cost
Loss of Earning
Neurology
Neuropsychology
Neuropsychiatry
Neurosurgery
Ophthalmology
Optometrist
Oral Surgery
Orthopaedic Surgeon
Otolaryngology (ENT)
Physiatry
Physician(GP)
Plastic Surgery
Psychiatry
Psycho-educational
Psycho-vocational
Rheumatology
Social Work
Speech-Language Pathology
Vocational
Transferable Skills Analysis
