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Get Allied Health Recovery Request

Ercise physiologist Counsellor Osteopath Chiropractor Other: Referred by (where relevant) Phone number Section 1: Client details Client name Phone number Date of birth (DD/MM/YYYY) Claim information Insurer Claim number Date of injury/accident (DD/MM/YYYY) Section 2: Clinical assessment Diagnosis Have you liaised with the treating medical practitioner? Yes No Is your diagnosis consistent with the medical practitioner s diagnosis of the compensable injury? Yes Unknown No (if.

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