COH Rehab Referral Form

Before you enter information
If you are referring someone else, do not enter their identifying or health information, or upload their documents, unless you already have consent from that person or their authorised representative, or have identified another lawful authority permitting you to provide it to COH Services Pty Ltd (COH Rehab) for this referral. If you cannot confirm this, contact COH Rehab first without including that person's identifying or health information or documents. You may use this form to enquire for yourself.
Consent wording updated 5 October 2026.
Privacy policy. Reading or acknowledging the privacy policy does not replace the consent or other lawful authority required before providing another person's information.

Tell us what help you need if you’ve been injured in a NSW motor vehicle accident.

Referrer Full Name

First NameLast Name

Occupation

Referrer Phone Number

Area CodePhone Number

Referrer Email Address

example@example.com

Client Full Name

First NameLast Name

Client Date of Birth

Date

Client Phone Number

Area CodePhone Number

Client Email Address

example@example.com

Claim Type

Insurer Name

Claim Number

Insurer Contact Name

Insurer Contact Email

example@example.com

Injury Date

Date

Diagnosis/Injury Summary

Current Treating Providers

I need help with:

Referral Reason and Goals

Urgent Risks or Accessibility Needs

Preferred Contact Method

Other

Upload Referral Documents

Before providing another person's identifying or health information, I confirm that I already have consent from that person or their authorised representative to provide it to COH Rehab for this referral, or have identified another lawful authority permitting this disclosure.

I confirm I have the authority to provide this information.

I confirm that client consent has been obtained or will be completed separately.

I acknowledge and accept the privacy policy.

Website

COH Rehab Enquiry Form