Workers Compensation Referral To make a Workers' Compensation referral please complete the form below: Injured Worker's DetailsInjured Worker's Name* First Last Date of Birth* Date Format: DD slash MM slash YYYY Sex*MaleFemaleBest PhoneIdeally a mobile phone number.Email* Address Street Address Suburb State Postcode Claim No.Injury DetailsRelevant Documents Drop files here or If available, please upload relevant documents, i.e. imaging reports, current medical certificate and/or IME report.Medical clearance for exercise programme attached?YesNoRelevant medical and rehabilition reports attached?YesNoGP DetailsGP's Name First Last Practice NamePhoneFaxEmail Address Street Address Suburb State Postcode Case Manager DetailsCase Manager Name First Last CompanyPhoneFaxEmail Billing Address Street Address Address Line 2 Suburb State Postcode PhoneThis field is for validation purposes and should be left unchanged.
