QUALITY REHABILITATION SERVICES

Quality Rehabilitation
Services Ltd.
Auckland,
Waikato
Bay of Plenty

Tel 0800 557 556
Fax 0800 557 559
admin@qualityrehab.co.nz

Referral Form

Case Manager Details
Organisation:
Phone:
Email:
Fax:
ACC/Customer Number:
Purchase Order Number:
Client Details
Name:
DOB:
Address:
Home Phone:
Cell Phone Number:
Diagnosis:
Date of Injury:
Employer Details
Job Title:
Address:
Work Phone:
Contact Person:
Specify Service Required:
Vocational Rehabilitation
Workplace Assessment
Workstation Assessment
Gradual Return to Work Programmes
Return to Work Monitoring
Stay at Work Assessments
Functional Capacity Evaluation
Pain Management
PGAP (Progressive Goal Attainment Programme)
Social Rehabilitation Assessments
Integrated Rehabilitation Assessments
Equipment for Independence
Housing Modifications
Single Discipline Assessments
Nursing Assessments

Wellness Checks and Programmes

Manual Handling Workshops

Medico Legal Assessments

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