Referrals - https://karprehab.com

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Virtual Care

Services
Languages
Locations
Referrals
Careers
Resources
Contact
Virtual Care

Referrals

To submit a referral, please fill out the form below. Referrals can also be submitted by telephone: 604-420-7800, fax: 604-420-7820 or email: [email protected]

- Referrer Information
- Referral Source*
  - Physician/Clinician
  - Adjuster
  - Lawyer
  - Self-referral
- Referrer Name
- Referrer Company / Clinic
- Referrer Phone
- Referrer Email
- Referral Services*
  - Select All
  - Active Rehab
  - Occupational Therapy
  - Physiotherapy
- Coverage (if multiple, select primary coverage type)*
  - ICBC
  - Personal Insurance
  - WorkSafe
  - Private Pay
- Reason for Referral
- Client Information
- First and Last Name
- Date of Birth
  MM slash DD slash YYYY
- Phone
- Email
- Personal Health Number - if applicable
- Claim Number
- Date of Loss
  MM slash DD slash YYYY
- Date of Injury
  MM slash DD slash YYYY
- Adjuster Name
- Lawyer Name
- Case Manager Name
- Case Manager Phone
- Case Manager Email
- Company Name
- Policy Number
- Preferred Location (Active Rehab only)
  - Downtown Vancouver
  - North Vancouver
  - East Vancouver
  - Richmond
  - Burnaby (Highgate)
  - Burnaby/Coquitlam (Lougheed) - Head Office
  - Surrey
  - Easy Surrey/Langley
  - Maple Ridge
  - Abbotsford
  - Chilliwack
  - Pitt Meadows
- Comments
Captcha
Email
This field is for validation purposes and should be left unchanged.

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