Referral Form

Please fill in and submit the form below. For help filling in this form please visit the WorkCover WA website.

Alternatively, you can print out the form and fax or mail it to one of our offices.

Details

Worker's Name
Address
Address Line 2
 
Workers Email*
Home Number
Mobile Number
Insurer
Claim Number
Date of injury

Referral

Status of Worker

Working / Full CapacityWorking / Partial Capacity Not Working / Full CapacityNot Working / Partial CapacityNot Working / No Capacity

Employer Details

Company
Contact Name
Address
Phone Email

Medical Practitioner

Practice
Name
Address
Phone Email

Source of Referral

Referrer

Name
Date