ARGENT REHABILITATION REFERRAL FORM
Date of referral:
INJURED PERSON INFORMATION
Title: Client’s Last Name: First: Middle:
Date of Birth: Sex: Male Female Marital Status:
Street address: City: Post Code:
Email: Home phone no: ( ) Mobile: ( )
OCCUPATIONAL INFORMATION
Employee work phone
Job Title / Occupation: Worksite location: Worksite address:
no.:
( )
Employee Salary (£): Duration with employer: Contracted hrs of work p/wk: At work?:
Yes No
Employer Contact Name: Employer Telephone: Claim made against employer Employer email address:
( ) Yes No
CLAIMANT SOLICITORS INFORMATION
Company Name: Solicitor Name: Address:
Phone no: Email Address: Fax no: Reference Number:
( ) ( )
INSURANCE / ADJUSTER INFORMATION
Claims Handler Name: Company Name: Address:
Phone no: Reference Number: Email Address:
Insurance type: Employers Liability Motor Public Liability Other
*On receipt of this referral form, you will receive a receipt confirmation within 1 working day.
If no confirmation of receipt is received please contact Argent Rehabilitation – 020 8774 6066.
ABOUT THE INJURY
Date of injury:
Primary illness or injury description:
Brief Description of what happened:
Details of current treatment, if known:
SERVICES REQUIRED
Argent allocate to appropriate services? Yes No
PRIMARY SERVICES ADDITIONAL SERVICES
Obtain joint instruction agreement
Ergonomic / Workplace Assessment
Treatment co-ordination: Physio, CBT, MRI etc Functional Capacity Evaluation (FCE)
Telephone Case Management Vocational Assessment
Immediate Needs Assessment Intensive Job Seeking Programme – New employer
Home Assessment / OT Assessment
Has Joint Instruction been confirmed? Yes No
Is claimant solicitor aware of referral to rehab provider? Yes No
Is injured person aware of your referral to rehab? Yes No Not known
Is any relevant documentation attached? Yes No
ADDITIONAL INSTRUCTIONS OR REQUIREMENTS
ARGENT REHABILITATION REFERRAL CONTACT DETAILS
Please send the referral to:
Email: newreferrals@argentrehab.co.uk
Post: 8 Bedford Park, Croydon, Surrey, CR0 2AP
Fax: 0208 774 6008
If you would like to discuss this referral in more detail before sending, please phone 020 8774 6066 and
ask to speak to Martin Thompson or Daniel Winn who will be able to assist you further.