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E-Referral

IHS Referral

Want to send us a referral?

Just fill-up the form.

Want to send us a referral?

Simply select the type of assistance you require, completing the mandatory fields and send to IHS by cllicking the submit button below:

The fields marked with * are required fields.

Injured Worker Details

Surname:

First Name:

Title:

Date of Birth: (dd/mm/yyyy)

Street Address:

Suburb:

Post Code:

Region:

Phone (Work)

Phone (Mobile)

Phone (Home)

Occupation:

Is English Second Language?

Injury Details

Date of Injury (dd/mm/yyyy)

Injury:

Employer

Company:

Contact:

Address:

Phone:

Fax:

Email:

Insurer

Company:

Contact:

Address:

Claim No.

Phone:

Email:

Nominated Treating Doctor

Name:

Address:

Phone:

Fax:

Specialised Services Required (please tick)*

Specialised Services

Proceed with a Return to Work Plan for same employer Initial Assessment only Workplace Assessment only Case Conference only Ergonomic Assessment Functional Capacity Evaluation Occupational Therapy/ADL Assessment Mediation/Conflict resolution Training Consultancy

Comments

Comments:

Referral Details

Title:

Referred by:

Phone Number:

Select one of the following:

Referred by their employer

Referred by their insurer

Referred by their doctor

Upload relevant documents here:

Attach File:

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IHS Referral

Want to send us a referral?

Just fill-up the form.

Want to send us a referral?

Simply select the type of assistance you require, completing the mandatory fields and send to IHS by cllicking the submit button below:

The fields marked with * are required fields.

Injured Worker Details

Surname:

First Name:

Title:

Date of Birth: (dd/mm/yyyy)

Street Address:

Suburb:

Post Code:

Region:

Phone (Work)

Phone (Mobile)

Phone (Home)

Occupation:

Is English Second Language?

Injury Details

Date of Injury (dd/mm/yyyy)

Injury:

Employer

Company:

Contact:

Address:

Phone:

Fax:

Email:

Insurer

Company:

Contact:

Address:

Claim No.

Phone:

Email:

Nominated Treating Doctor

Name:

Address:

Phone:

Fax:

Specialised Services Required (please tick)*

Specialised Services

Proceed with a Return to Work Plan for same employer Initial Assessment only Workplace Assessment only Case Conference only Ergonomic Assessment Functional Capacity Evaluation Occupational Therapy/ADL Assessment Mediation/Conflict resolution Training Consultancy

Comments

Comments:

Referral Details

Title:

Referred by:

Phone Number:

Select one of the following:

Referred by their employer

Referred by their insurer

Referred by their doctor

Upload relevant documents here:

Attach File:

Powered By ChronoForms - ChronoEngine.com

ASSESSMENT SERVICES

Initital Assessment
Workplace Assessment
Ergonomic Assessment
Medico Legal
Activities of Daily Living
Functional Capacity Evaluation

INJURY PREVENTION

Suitable Duties Registers
Ergonomic Assessment
Pre Employment Screening
Training

RETURN TO WORK SERVICES

Case Management for RTW Same Employer
Mediation/Negotiation Services
Case Conferencing

TRAINING SERVICES

Ergonomic Training For Office Staff
Manual Handling Training
Stress Management
Fatigue Management
Rehabilitation Strategies For Supervisors & Line Managers

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