Skip to main content
Navigation
About Lifemark Health Group
Services
Careers
Contact Us
Referral form
You must have JavaScript enabled to use this form.
Referral company information
Referral company
Referral person
Policy number
Claim
Address
Phone No.
Fax No.
Email address
Client information
Client
Date of birth
Date of disability
Diagnosis
Address
Phone
Employment information
Employer
Occupation
Employer contact
Phone
Address
RTW goal
Own occupation
Any occupation
Other
Enter other…
Service request
(please select all that apply)
Treatment services
Physiotherapy
Work conditioning
Occupational therapy
Exercise reactivation
Cognitive rehab program
Cancer rehab program
Concussion rehab program
Vestibular rehab program
Psychology program
LIFT - Tier 1
LIFT - Tier 2
LIFT - Tier 3
LIFT - Tier 4
Other
Enter other…
Assessment services
Ergonomic Ax
Physical demands analysis
Cognitive demands analysis
Workplace accommodation assessment
1-day Functional Capacity Evaluation (FCE)
2-day FCE
1-day Cognitive Abilities Evaluation (CAE)
2-day CAE
2-day FCE/CAE
IME
Enter other…
Special instructions
Secure file upload
Upload
Upload requirements
Submit
Leave this field blank
