Referral Form

Referral Form for Axis Injury Management Services

Worker Information

Worker First & Last Name

Worker Claim Number

Worker Date of Birth

Worker Contact Number

Worker Email Address

Worker Address

Street address

City

State

Postcode

Worker Occupation Title

Worker Injury Type

Worker Date of Injury

Date Ceased (if off work)

Current Work Status

At Work Off Work

Attachments - WorkCover Certificate of Capacity, Medical Reports, Other

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Employer Information

Employer Company Name

Employer Contact Name / Return to Work Coordinator

Employer Contact Number

Employer Email Address

Employer Address

Street address

City

State

Postcode

Insurer Information

Insurer Company Name

Insurer Contact Name

Insurer Email Address

Insurer Contact Number

Doctor Information

Doctor Medical Centre

Doctor Name

Doctor Contact Number

Doctor Email Address

Doctor Fax Number

Treating Doctor Address

Street address

City

State

Postcode

Treating Specialist Information

Treating Specialist Name

Treating Specialist Contact Number

Treating Specialist Email Address

Treating Specialist Fax Number

Treating Psychologist Information

Treating Psychologist Name

Treating Psychologist Contact Number

Treating Psychologist Email Address

Treating Psychologist Fax Number

Other Health Practitioner Information

Contact Name

Contact Number

Contact Email Address

Contact Fax Number

Requested Services

Interpreter Required

YesNo

Language

Liability Accepted

YesNoI dont know

Comments / Additional Information

Is the Worker aware they have been referred to Axis Injury Management *

I authorise Axis Injury Management to collect, use, and disclose the information provided in this referral for the purposes of assessing the referral, requesting insurer approval, and facilitating the provision of services. *

Referrer Name

Referrer Company

Referrer Position

Signature *

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Date

Thank you for referring to Axis Injury Management

Kind Regards,
Axis Injury Management

Phone: (02) 4927 0577 / 1300 120 024
Fax: (02) 4920 7080
Email: admin@axisinjury.com.au
Web: www.axisinjury.com.au

Suite 13 (First Floor)
20-22 Smith Street
CHARLESTOWN NSW 2290