Referrals

Service Referral Forms

We have different forms that tie directly to the service you are looking to refer. We request that you be precise as possible when answering the questions asked, or when filling out the necessary detailed sections. A Douglas Arnold MPC staff member plans to be in touch within the next 48 hours. To access a form, simply click on one of the seven menus below. The specific form you are looking for should automatically appear.

PREPLACEMENT TESTING

PREFERRED METHOD OF CONTACT: EmailPhoneFax

Select the need of these preplacement services.

REQUIRED FORM: YesNo

HEARING TEST: YesNo

VISION SCREENING: YesNo

PULMONARY FUNCTION TESTING: YesNo

JOB COMPATIBILITY ANALYSIS: YesNo

DRUG OR ALCOHOL SCREENING: YesNo

Additional details you wish to share about the referred client.

INDEPENDENT MEDICAL EXAMINATION

PREFERRED METHOD OF CONTACT: EmailPhoneFax

Answer yes or no to the following required questions.

IS THIS A WSIB CASE: YesNo

IS THIS A NON-OCCUPATIONAL INJURY: YesNo

IS THIS A NON-OCCUPATIONAL ILLNESS: YesNo

IS THERE SUPPORTING DOCUMENTATION AVAILABLE: YesNo

Briefly describe the problem that has occurred.

PHYSICAL DEMAND ANALYSIS

PREFERRED METHOD OF CONTACT: EmailPhoneFax

Describe the job classification that requires this physical demand analysis.

ATTACH THE CURRENT PDA DOCUMENT, IF AVAILABLE.

[attachment]

NURSING ASSESSMENT

PREFERRED METHOD OF CONTACT: EmailPhoneFax

Check all of the assessment services that are required.

Include any additional details you would like to share.

ERGONOMICS ASSESSMENT

PREFERRED METHOD OF CONTACT: EmailPhoneFax

Check all of the ergonomic settings that are to be assessed.

Include any additional details you would like to share.

MINE RESCUE

PREFERRED METHOD OF CONTACT: EmailPhoneFax

YEAR OF LAST PULMONARY FUNCTION TESTING:

Share any specific requirements needed for your group.

HOIST MEDICAL

PREFERRED METHOD OF CONTACT: EmailPhoneFax

YEAR OF LAST PULMONARY FUNCTION TESTING:

Share any specific requirements needed for your group.