Medicolegal Form Preferred Clinician: Referrer Details Referrer's Name: * First Last Referrer Company: * Referrer Phone Number: * Email Address * Solicitor's Name: First Last Solicitor's Phone Number: Claim or Reference Number: Clients Details Client's Name: * First Last Date of injury: * What are the client's injuries / diagnosis? * Client's Phone Number: * This will only be used to confirm the appointment and address. (Mobile preferred) Client's email address: This will only be used should the assessment take place via video conference due to COVID-19 Client's Location / Address: * Client's Date of Birth: Date Report is Required by: Please note our report turnaround is 3-4 weeks from date of assessment. Interpreter Required: * Yes No It is the referrer’s responsibility to organise an accredited interpreter to be present for the assessment if one is required.(Must be certified with Accreditation Authority for Translators and Interpreters; family members or friends cannot be used) Contact Name for Interpreter: First Last TELEHEALTH Due to the COVID-19 situation we are requesting this section is completed at time of referral Does the client have internet service and a computer, tablet or smart phone: Yes No Is the client happy to proceed with a video health conference (via phone or device) Yes No Does the client have a support person who can hold the device Yes No *SAFETY - Are there any known risks (including violence, aggression, drug / alcohol use or behaviour) which would place our MRO staff at risk conducting a home assessment? * Yes No If yes; please provide further details: *SAFETY (COVID-19) Has the client or anyone in the household had known exposure to COVID-19, is high risk or vulnerable (i.e. immunosuppressed or over 65 years), has travelled overseas 14 days prior to the assessment and / or is not feeling well, showing signs of fever, shortness of breath or flu-like symptoms? * Yes No If yes; please provide further details: Please provide any further information: Please note: In order to conduct the assessment, hard copies of the letter of instruction and medical documents must be sent via registered or express post to PO Box 4303, Shellharbour, NSW 2529 no later than two weeks prior to the scheduled appointment date. (Please email the tracking number to firstname.lastname@example.org when sent).