Client Referral Form

Client Referral Form
Who is making this referral?
Law Firm / Rehab Company Name
Law Firm (legacy free text - retired, kept for historical data)
Your firm name
Only if you selected Other above
Organization name
Do you have a lawyer, case manager or insurer involved? (optional)
Your name

First NameLast Name
Your email
Use your own email. Do not enter the patient's email address here.
Your phone
Please enter a valid phone number.Format: (000) 000-0000.
Send updates about this referral to someone else as well? (optional)
Their email address
Secondary Contact (If Applicable)

First NameLast Name
Secondary Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Secondary Contact Email
example@example.com
Patient Information
Patient's full name

First NameLast Name
Patient's phone number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's email
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Gender (optional)
Province of Residence
Province (legacy free text - retired, kept for historical data)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client's Secondary Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Date of accident or injury (if applicable)

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Services requested (Select all that apply)

Other form or service (tell us which form)
Ontario-Specific Services (Select all that apply)
Atlantic services (Select if applicable)
Date of Initial Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Reason for Follow-up
Has your firm approved the expense for this follow-up?
Does the client have OHIP coverage?
Funding arrangement (legacy radio - retired, kept for historical data)
Is there anything we should know about how care will be funded?
How would you like us to proceed with funding?
Did the client purchase optional accident benefits (such as income replacement) on their auto policy?
Insurer Name
Claim Number
Adjuster Name and Contact
Legal Priorities + Client/Patient Concerns
Will your client require the assistance of an interpreter?
Interpreter language required
Interpreter (legacy checkbox - retired, kept for historical data)
Upload any records you have (optional)

Cancelof
Consent
Status updates
Circle Bay Medical protects personal health information under Ontario's Personal Health Information Protection Act and the privacy laws of each province we serve. Information you submit is used only to arrange and provide care. Privacy Policy
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Client Referral Form

Patient Information