Client Referral Form
Law Firm / Rehab Company Name
*
Please Select
Aaron Waxman & Associates
Advocai Law
AMR Law
Badre Law
Bergel Law
Bonn Law Office
Brooker Law Office
BurnTuckerLachaine
Campisi Law
Chowbay Law
Coastal Injury Law
Cohen Highley
Dahab Law
David Hollingsworth
DS Law
Eagles Landing Medical Centre
Elite Specialist Group
Fidelis Law
Ghai Law
Girones Bourdon Kelly Lawyers
Gluckstein Lawyers
Harris Law
Himelfarb Proszanski
Howie Sacks & Henry
Innovative Care Management
John Edwards
Kahler Law
Katzman-Wylupek
Knorr & Associates
Maana Law
MacGillivray Law
McNally Gervan
Merwar Lawyers PC
Mike Murphy Law
Naimark Law
NI Lawyers P.C
Nova Injury Law
Oatley Vigmond
Orendorff & Associates
Pace Law
PM Injury Law
Semko Law
Slomyanski Law
TSF Law
VC Lawyers
Waterhouse & Associates
ZSRH Litigation Lawyers
Other - my firm is not listed
Law Firm (legacy free text - retired, kept for historical data)
Your firm name
Only if you selected Other above
Main Contact
*
First Name
Last Name
Your Work Email
*
Use your own work email at the firm. Do not enter the client's email address here.
Your Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact (If Applicable)
First Name
Last Name
Secondary Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Secondary Contact Email
example@example.com
Client Information
Client's Full Name
*
First Name
Last Name
Client's Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Client's Email
example@example.com
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Gender
*
Male
Female
Province of Residence
*
Please Select
Ontario
Nova Scotia
New Brunswick
Prince Edward Island
Newfoundland and Labrador
Other
Province (legacy free text - retired, kept for historical data)
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Client's Secondary Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Core Services Required (Select all that apply)
*
Initial Consultation + Clinical Record
Follow-up Visit
CPPD Application
Disability Tax Credit Application
LTD Application
ODSP Form
Other
Ontario-Specific Services (Select all that apply)
MIG Report
OCF-3
OCF-19
IRB Support Documentation
Date of Initial Visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for Follow-up
Has your firm approved the expense for this follow-up?
*
Yes, approved
No, please confirm with our firm first
Does the client have OHIP coverage?
*
Yes
No
Client has no provincial health coverage. Please confirm the funding arrangement.
*
Our firm will cover the visit
Client will self-pay
Need to discuss with Circle Bay Medical
Is an HCAI submission required?
*
Yes
No
Date of Loss / Accident Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insurer Name
*
Claim Number
*
Adjuster Name and Contact
Legal Priorities + Client/Patient Concerns
Will your client require the assistance of an interpreter?
*
Yes
No
Interpreter language required
Interpreter (legacy checkbox - retired, kept for historical data)
Yes
No
Submit
Should be Empty: