AssessMed Appointments

Friday 5, September 2008

APPOINTMENTS

Type of Assessment Required

Functional Medicine Evaluation	Neurological Assessment
Insurer's Examination & Functional Abilities Evaluation	Vocational Assessment
Insurer's Examination	Transferable Skills Analysis
Independent Medical Evaluation	Labour Market Survey
Psychological Assessment	Dental Assessment
Neuropsychological Assessment	TMJ Assessment
Activities of Daily Living Assessment (RN)	Ophthalmological Assessment
In Home Assessment (OT)	Otolaryngolical (ENT) Assessment
Form 1	Cardiological Assessment
Job Demands Analysis	Internal Medicine Assessment
Psychiatric Assessment	Paper File Review

Your Information

Company Name:		Contact Name:
Address:
City:		Prov.:
Postal Code:		E-Mail:
Phone:		Fax:

Third Party Billing (If Applicable)

Company Name:		Contact Name:
Address:
City:		Prov.:
Postal Code:		E-Mail:
Phone:		Fax:

Evaluee

Evaluee Name:	Date Of Birth:
Address:
City:	Prov.:
Postal Code	Gender	Male Female
Special Instructions:

Legal Representative (If Applicable)

Company Name:		Contact Name:
Address:
City:		Prov.:
Postal Code:		E-Mail:
Phone:		Fax:

Notes

Case Particulars

Reference Number:		Injury or Illness:
Reference Date:		Occupation:

Additional Services Required

Interpreter Required	Language
Transportation Required	Hotel Accomodations

AssessMed to contact you by:

Telephone Email Fax Other

Should you require assistance with any of the preceding fields, please contact AssessMed by
Email at inquiries@assessmed.com or by phone in the GTA (416) or (905) local at
(905) 678-2924 and at 1-888-678-2924 for calls outside of this area.
AssessMed offices service the greater Toronto Area including Hamilton and Niagara region.

AssessMed uses a secure server. All information is optional and will be kept strictly confidential.