CIRA Medical SERVICES

Confidential Referral Form – Medical Legal Clients

law firm Information

Law Firm
Plaintiff Counsel / Yes / No / Defense Counsel / Yes / No
Street Address / * only necesary to complete if this is your first referral to us / City Prov Postal Code / * only necesary to complete if this is your first referral to us
Lawyer’s First Name / Lawyer’s Last Name
Assistant’sFirst Name / Assistant’s Last Name
Phone / Fax # / Email Address
Date of Injury
(mm/dd/yyyy) / File/Reference Number
MVA / Yes / No / Other: (Please indicate)

EXAMINEE information

First Name / Last Name
Sex / Male / Female / Date of Birth
(mm/dd/yy)
INSURANCE COMPANY (Please check if not applicable or not available )
Tort Insurer
Accident Benefits Insurer

FILE Description

Diagnoses
How many inches of medical documents will you be sending? / How? / Mail / Fax / Courier / Other

requested assessments

Physical Assessments – Medical File Review or In Person Examination
Anesthesiology / Audiology / Cardiology / Chiropractic / Dentistry
Dermatology / Endocrinology / Gastroenterology / General Surgery / General Practitioner
Hematology / Infectious Disease / Internal Medicine / Immunology / Neuro-Opthamology
Neurology / Neurosurgery / Occupational Medicine / Orthopedic Surgery / Ophthalmology
Oral Surgery / Oncology / Otolaryngology (ENT) / Pediatrics / Physiotherapy
Plastic Surgery / Physiatry / Respirology / Rheumatology / Social Worker
Speech Language Pathology / Thoracic Surgery / Urology / Vascular Surgery / Other Specialty
Combined FME
Psychological / Psychiatric Assessments
Neuropsychology / Forensic Psychiatric Workplace Assessment / Psychiatry / Psychology
Functional & Vocational Assessments
Job Site Analysis (JSA/PDA) / Functional Abilities Evaluation (FAE/FCE) / Ergonomic Assessment / Other
Vocational / Vocational with TSA & LMS / Psychovocational / Other
Diagnostic Imaging
Bone Scan / CT Scan / MRI / X-ray / Other


additional services to be arranged by Cira

Transportation
Ground
Air / Yes / No / From / To
Translation
Required / Yes / No / Language:
Accommodation Required / Yes / No / Insturctions:
Please note that transportation and translation services will be arranged by Cira at no additional administrative cost. An invoice from the transportation and/or translation company will be sent directly to the referral source for payment.

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