Make a ReferralHome » Make a ReferralReferral Form To start services as quickly as possible we need the following details:• Client Details (Name, Contact Number, Suburb, Claim Number) • Insurer Details (Company, Contact Person, Email Address or Contact Number) • Doctor Details (Practice, Contact Person, Contact Number) • Referrer Details (Company, Contact Person, Email Address, Contact Number)If you have this information simply drag and drop the information below in file or image format. Drop files here or Can you please type some brief details below to ensure we have accurate information to begin services.*Referrer DetailsReferrer Contact Person First Last Referrer RoleReferrer OrganisationPhoneEmail Client DetailsClient Name First Last Client PhoneClient SuburbClaim NumberAgent / Insurer DetailsAre the Agent/Insurer details the same as the Referrer details?YesNoContactCompany NamePhoneEmail Treating Doctor DetailsName First Last PhoneCommentsThis field is for validation purposes and should be left unchanged. Returning to Health, Life & Work We are the specialists in Workplace Injury Treatment. Call us now on 1300 591 435. Contact us today!
