Workplace Rehabilitation Referral 1. Worker’s Information* First Last Date of Birth* DD slash MM slash YYYY Telephone numberClaim Number Insurer Date of injury DD slash MM slash YYYY Injury type Worker’s address2. Referring source Treating medical practitioner Employer Insurer on behalf of employer (authority attached) 3. Referral Type(Medical practitioners and employers must always consult with each other and the worker prior to the referral for rehabilitation assessment) Workplace rehabilitation assessment (Medical practitioners and employers must always consult with each other and the worker prior to the referral for rehabilitation assessment)If for a Specific Service only (please indicate) Functional capacity assessment Job demands assessment Ergonomic assessment Workplace assessment Other Other I have discussed this referral with the worker and their Employer or Treating medical practitioner and they are in agreement. Referrer’s name Date MM slash DD slash YYYY 4. Employer's DetailsCompany name Contact name TelephoneAddressTreating Medical Practitioner DetailsPractitioners name Practice name TelephoneAddressFile Drop files here or Select files Max. file size: 10 MB.