Medico-Legal Referral Form

Client Details

Client First Name *

Last Name *

Preferred Name *

Date of Birth (DOB) *

Gender *

FemaleMalePrefer not to sayOther

Other/Requested Name

Phone Number *

Email Address *

File # *

Address *

Street address *

City *

State *

Postcode *

Accident/Incident Details

Date of Accident/Incident *

Type *

Motor Vehicle AccidentPublic LiabilityWorkplace AccidentMedical Negligence

Sustained Injury/Injuries *

Brief Description of Accident/Incident *

Description of Events to Date *

Requested Service

Service *

Medico-Legal ReportSupplementary ReportOther (detail below)

If other, please explain

Time of Assessment Request * Note: Please allow for 6 weeks post final specialist assessment to (as best possible) ensure all specialist reports are to hand prior to review/assessment

Specialist Appointments Booked *

Requested Assessment *

Revive OT Office - Bli Bli, QLDTelehealth (video conference)Other (please detail below)

Please note: All assessments are conducted at the Revive OT Office in Bli Bli, QLD unless otherwise specified in this referral form.

If Other, please explain

Brief of Materials (if available)

Law Firm Details

Law Firm *

Solicitor *

Email Address *

Phone Number *

Referral Source Type *

GoogleSocial MediaWord of MouthOther

Other Details