Dynamic Occupational Health Solutions. Injury Prevention and Workplace Rehabilitation Phone: 1300 795 062 Fax: 1300 795 063 Email: info@dohs.com.au Select from the following: An overview of all services Workplace Rehabilitation - Same Employer Workplace Rehabilitation - Different Employer Pre-employment Screening Medico-Legal Assessments Premium Management Consultancy Ergonomic Assessment CTP Case Management Life Insurance Training and Health and Safety Consultancy

Referrer Details Referrer Company Referrer Contact Name Referrer Telephone Referrer Email About the Referrer: Insurer Employer Treating Doctor Injured Worker Treating Health Professional Other: Service(s) Required Workplace Rehabilitation Case Management CTP Case Management Life Insurance Case Management Public Liability Case Management Initial Assessment Workplace Assessment Vocational Assessment Functional Capacity Evaluation Section 40 Assessment Development of Return to Work Plan Occupational Health and Safety Consultancy Ergonomic Assessment Occupational Therapy Assessment Other: Injured Person's Details Full Name Telephone Email Address Date of Birth Gender Occupation Claim Number Current Work Status: Totally Unfit Suitable Duties Pre-injury Duties Employer Details (Workplace) Employer Company Employer Contact Name Employer Telephone Employer Email Employer Address Insurer Details Insurer Company Insurer Contact Name Insurer Telephone Insurer Email Insurer Claim Number Liability Accepted: Yes No Provisional Treating Practitioner Practitioner Company Practitioner Contact Name Practitioner Telephone Practitioner Email About the Practitioner: Treating Doctor (GP or NTD) Specialist Physio Other: Injury Description Date of Injury Nature of Injury Additional Information Comments Home • About Us • Our Services • Contact Us • Service Referral Form • Return to top of page Dynamic Occupational Health Solutions Pty. Ltd. Phone: 1300 795 062 Fax: 1300 795 063 Enquiry form Suite 447 311-315 Castlereagh Street Sydney NSW 2000 PO Box 380 Rozelle NSW 2039 NSW WorkCover Accreditation No: 525 ABN 74 127 273 394 © Dynamic Occupational Health Services 2009