Employment Medicine Second Opinion Medicine Referral

Employment Medicine Second Opinion Medicine Referral
Referral information

The Second Opinion Medicine service is a clinical support service available to all treating medical practitioners with patients in the Return to Work scheme for quick access to clinical advice from a medical specialist.

The treating medical practitioner retains patient care and is under no obligation to implement the recommendations, although it is strongly encouraged.

This is not a referral for treating and does not fast track a treating referral. It is a stand-alone once off service.

THIS IS NOT A MEDICO-LEGAL SERVICE
This form can be saved and completed at a later time.

You will receive an email with a link to resume filling out the form.
Referral Date

DayMonthYear
Date
Email
example@example.com
Claims agent (if known):
Reason for referral:

Worker’s details:
Claim number (if known):
Worker’s full name:

First NameLast Name
Gender:

Other
Worker's Date of birth:

DayMonthYear
Date
Worker's Mobile Phone Number
Please enter a valid phone number.Format: 0000-000-000.
Worker's Alternate Phone Number

Area CodePhone Number
Worker Email Address (if known)
example@example.com
Interpreter required: Y / N: If yes, please specify language:
Interpreter language required
Is the worker aware of referral?:
If worker is not aware of this referral, please specify the reason why not.

Medical information
Accepted injury:
Worker's Injury Date

DayMonthYear
Date
Certifying doctor name:
Certifying Doctor Contact Details:
Certifying Doctor Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Certifying Doctor Email Address
example@example.com
Preferred day and time for specialist to contact:
Contact Date

DayMonthYear
Date
Hour MinutesAM/PM Option
Other relevant information:
Additional information incl. social information / other medical conditions :
Please verify that you are human
Should be Empty: