Case Referral Form

  • Complete the form below to refer your case for our Doctors to review.

    * Required Field

    Case Details

  • Date Format: DD slash MM slash YYYY
  • Your office location.
  • Incident Details

  • Date Format: DD slash MM slash YYYY
  • Date Format: DD slash MM slash YYYY
  • Supporting Files

    In order for us to help you with your case please consider attaching the following:

    • The CNF/Letter of Claim
    • Medical Legal Reports
    • Medical Notes
    • Rehabilitation Reports
    • Medical Correspondence
    • Stage 2 Settlement Pack

    Please note the acceptable file types are doc, docx, xls, xlsx, pdf, zip, jpg, png. Each file can be a maximum of 10Mb and you can attach up to 10 files.

  • Drop files here or
    Accepted file types: doc, docx, xls, xlsx, pdf, zip, jpg, png.