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
Diamond & Diamond
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
Did the client purchase optional accident benefits (such as income replacement) on their auto policy?
Yes
No
Unknown
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: