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Make a Referral

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1 - Referral Information

Your relationship to the Client *

Insurance Adjuster / Rehab Specialist

Doctor

Lawyer

Occupational Therapist

Veteran Affairs

I am the client

Other

Your Name *

Telephone # *

Fax #

Email *

Same as above.

Client Name *

Date of Birth

Date

E.g., 2019-12-09

Telephone # *

Address

Claim #

PHN (Personal Health Care) #

Date of Injury

Date

E.g., 2019-12-09

Doctor Name

Telephone #

Lawyer Name / Firm Name

Telephone #

Details of Injury

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3 - Referral Type

What type of service are you looking for?
Information regarding our services can be found in the "Our Services" section of the website. Please include any addtional information at the bottom of this section.

Occupational Therapy

Coordination of Hospital discharge

Case Management

Coordination of Rehabilitation services

Home Assessment

Cognitive Assessment

Return to Work Intervention

Seating Assessment

Other

Kinesiology

Exercise Therapy / Active Rehab Program

Hydro Therapy

Work Conditioning / Work Hardening

Home Program

Functional and Cognitive Re-Training

Activation Program

Personal Training

Report Type

Initial

Progress

Discharge

Ergonomic Evaluation

Job Demands Analysis

Workplace Ergonomic Evaluation

Additional Information

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4 - Payer Information

Please send invoices to the Attention of:

Name

Telephone #

Company

Address

Additional Information

What code is in the image? *

Enter the characters shown in the image.

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Phone: 604.589.5994
Fax: 604.589.5992
Address:
P.O. Box 74007
Unit 103, 16033-108th Ave
Surrey, BC V4N 1P2
Canada

Testimonials

Very professional team! Always paying close attention to the patient while working out. I highly recommend them especially if the injury is serious. Shawna is a very positive and professional...

Nathalie L., Client

more

What is Shockwave Therapy?

Submitted by Shawna on Wed, 11/20/2019 - 12:52

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