Referrals - Institute of Occupational Medicine ConsultingInstitute of Occupational Medicine Consulting

For service requests, please complete and submit the following form. A representative from IOMC will respond as soon as possible.

REFERRAL SOURCE INFORMATION Please provide the following information about the referral source
Company Name *
Type of Company *
First Name *
Last Name *
Company Address *Please type full address, including city, province, and postal code
Email *
Phone *
Fax
CLAIMANT / EXAMINEE INFORMATION Please provide the following information regarding the claimant
First Name *
Last Name *
Date of Birth
Date of Loss *
Claimant Address *Please type full address, including city, province, and postal code
Phone *
Email
Legal Representative (if any)
Interpreter required?
YesNo
If you answered 'Yes' to the interpreter requirement, Please specify language:
Additional Comments and Questions
Here you can inform us if this referral is urgent
Examinee Documents Upload