RACQ Telehealth Referral - Axis

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Premium Care Program

RACQ Telehealth Referral to Axis

Alternatively, call Axis on (07) 3229 9441 to organise a booking.

Referrer Details

Referrer Name(Required)

Referrer Organisation

Referrer Postal Address

Referrer Phone

Referrer Fax

Referrer Email

Client Details (if applicable)

Client Name(Required)

Client Claim No

Client DOB

DD slash MM slash YYYY

Client Contact

Client Address

Client Occupation

Client Email

Employer Details (if applicable)

Employer Name

Position

Employer Contact

Employer Fax

Employer Address

Treating Doctor/s

Treating Doctor/s Contact

Treating Doctor/s Address

Condition(Required)

Date Of Injury

dd/mm/yyyy

Additional Information

Services

Service

Premium Care Program

Physio treatment

Psychology counselling

AXIS Functional restoration and pain management program

Screening assessment (for suitability for above program)

Ergonomic workstation assessment

Worksite assessment/ Return to work services

Independent Physio Case review

Gym program

Functional Capacity Evaluation (FCE)

Job Task Analyses/Job dictionary

Pre-employment screenings

Risk assessment

Hazardous Manual Task Training

Health Assessments

Wellbeing seminars, workshops, and webinars

Health Challenges

Injury Prevention Programs

Other

I would like Axis to:

I would like Axis to:

Contact the patient & commence treatment immediately

Make contact with me prior to commencing services

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