Quick referral form
Fields marked with an * are required.
Service type and business line
Service Type
IME
File Review
Other
Business Line
Workers’ Compensation
First-Party Auto
Third-Party Auto
Liability
Disability
Other
Company information (referral source)
Company name*
City*
Province*
QC
BC
AB
SK
YT
NT
MB
ON
NS
NL
NB
PEI
Contact first name*
Contact last name*
Phone*
Email*
Claim information
Claimant last name
Assessment location (if in person)
Preferred language
Other location option
Requested assessor
Requested specialty(ies)
Chiropractic
Psychiatry
Occupational therapy
Neurosurgery
General practitioner
Psychology
Neurology
FCE
Physical medicine & rehabilitation
Orthopedic surgery
Neuropsychology
Kinesiology
Other
Additional information
Submit
