Workers Compensation Claim

for Remedial Massage Request

Form

Please fill out the following form and we will respond as soon as we can.

First name

Last name

Date of Birth

Phone

Who is your Insurer for the workcover claim?

Do you have a Case Manager for your claim? What is their name and email?

What is your Claim Number?

Date of inury/accident (DD/MM/YYYY)

Describe the injury and how it happened?

Have any other providers been treating you? ie physio, chiro, exercise physiologist etc. What is their name and contact?

What was your pre-injury capacity at WORK (occupation, tasks, days/hours worked)

What is your current capacity for WORK?

What was your pre-injury capacity at HOME? (self care, domestic, caring)

What is your current capacity at HOME?

What was your pre-injury capacity in COMMUNITY? (driving, transport, leisure)

What is your current capacity in COMMUNITY?

Thanks for submitting!

One of our therapists will be in contact with you.