Demo

Corporate Office:

The Health Plex
114 Empire Avenue
St. John’s, NL
A1C 3G2
Tel: 709-722-7676
Fax: 709-722-6029

Branch Office:

234 Villa Marie Drive
P.O. Box 1910
Marystown, NL
A0E 2M0
Tel: 709-279-7676
Fax: 709-279-7677

Branch Office:

8 Gullage Avenue
Corner Brook, NL
A2H 7J4
Tel: 709-632-7676
Fax: 709-634-1015

Branch Office:

1495 Topsail Road
Paradise, NL 
A1L 1R1
Tel: 709-748-7676
Fax: 709-368-4037

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Please fill out the details requested below. Note there are 2 pages to this form.



Referred Information




Client Name(*)

Please type your full name.

Client Phone Number(*)

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Treating Doctor

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Date of Birth
/ /
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Diagnosis or Injury Type / Date of Injury

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Occupation

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Employer(*)

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Referrer Information




Claim/PO #

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Referring Party(*)

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Billing Address(*)

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Billing Contact(*)

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E-mail(*)

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Workplace Contact(*)

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Phone Number(*)

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Employment Services
















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Occupational Rehab













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Disability Management













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Vocational / Labour Market Re-Entry







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Workforce Reentry Services Options





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If you selected an assessment service, what question(s) do you want answered from the assessment?

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Supporting Documents

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In instances when an appointment is cancelled with less than 2 business days notice or there is a “no show” by the client, a cancellation fee will apply if the appointment time cannot be reassigned. Cancellation fees are approximately 35% of the fee associated with the service. By submitting this referral form you are agreeing that a cancellation fee may apply to this referral. Any questions can be directed to info@fitforwork.com.

* For Disability Management and Occupational Rehabilitation Services please provide recent medical documentation. Failure to do so may result in postponement of services.




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Anti Spam

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