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Re:Function Referral – Medical Legal Services

How can we help?

Required boxes are indicated with *

Referral Source Information

I am inquiring about?

* Lawyer Name

* Lawyer Phone #

Lawyer Fax #

* Lawyer Email

* Law Firm Name

Law Office Address


Postal Code

Assistant/Paralegal Name

Assistant/Paralegal Phone #

Assistant/Paralegal Email

* Do you represent Plaintiff or Defence?

* Confirmation email to be sent to

Client Info Section

Client Name (include English name, where applicable)

Date of Birth

Client Address (If CFC is required)


Postal Code

Claim No.

File No.

Report Deadline

Trial Date

Trial Duration

Date of Injury

Is an Interpreter Required?

Language Required

Gender of the Client

*If referring for a consult

Please provide a list of reports to be reviewed, along with their corresponding clinicians

Will a rebuttal report be required, or only a verbal opinion/aid with trial prep?

Extra Info Section

* How did you hear about us?

Additional Comments

Exceptional People.

Exceptional Service.

Function is our Focus