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Occupational Medicine Referral Form

Tel. 604-503-0490 Fax. 604-503-0492
301B- 6935 120 Street, Delta BC V4E 2A8
www.medilinkconsulting.ca

First Name, Last Name

Address & Email

Phone number

Date of Birth

MODALITY OF PAYMENT

WCB Claim number

Private

Extended Health Benefit ( Name & Plan #)

Injury Date

Occupation

REFERRAL SOURCE

Law Office

Insurance Company

Employer

Union

Self

Other ( Please specify)

REQUESTED ASSESSMENT

Pre employment assessment

Periodic health assessment

Drivers' medical exam

IME: Independant Medical Examinations

ICBC cases (road accidents exams)

WBC cases (injury at work)

Other (Please specify)

A. When did the problem start?

B. Scale of pain: 1- 10 ( 10 being the highest)

C. Where is the problem ( please tick on the diagram)

Head

Additional comments

Initials

Today's date

I declare that the info I’ve provided is accurate & complete

Thanks for submitting!

Medical Clinic in Delta, British Columbia

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