Employee Referral Form

 

Employee

Sex: M F

Family Practitioner

Employer

Injuries / Diagnosis (please comment, if applicable)

Health Prevention

Education & Safety Training
Pre-Placement Functional Assessment
Physical Demands Analysis
Ergonomic Assessment
Post-Offer Employment Testing
Fitness to Work Testing

Injury Management

Neurological IME
Occupational Therapy Assessment
Psychiatric IME
Disability Management
Psychological IME
Functional Capacity Evaluation
Physiatry IME
Vocational Rehabilitation Assessment
Orthopaedic IME
Return to Work Program
Work Harding Program
Early Intervention Rehabilitation Program
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