Refer occupational therapy & injury rehabilitation clients- Raincoast Rehab

Client's Name*

First Last

Date of Birth*

Age*

Personal Health Number*

Date of Injury*

Home Phone*

Cell Phone

Email Address*

Emergency Contact and Relationship*

Phone Number*

Name of Family Physician*

Address*

Street Address Address Line 2 City Province Postal Code

Contact Information

Please Check*

Is this referral the result of a motor vehicle accident or related to the ICBC?
Is this referral the result of a workplace injury ore related to WorkSafeBC?
Neither

Referral Source: (e.g. hospital, family doctor, lawyer, WorkSafeBC, ICBC, etc.)*

Name

First Last

Case Number (if applicable)

Claims Coordinator (if applicable)

First Last

Address

Street Address Address Line 2 City Province Postal Code

Phone Number

Email Address

REFERRALS