To refer a claimant / employee for an FCE:

Please fill out the form below completely.  You will be contacted via
email to confirm the referral and again once it is schedule.  Thank
you for your business.
PATIENT INFORMATION
Name:
Address:
City:
 State:
 Zip:
Phone 1:
 Phone 2:
Is a translator needed?:
(If yes, please provide language)
SS #:
 DOB:
 Date of injury:
Diagnosis:
REFERRAL INFORMATION
Name:
Company:
Address 1:
Address 2:
City:
 State:
 Zip:
Phone #:
 Fax #:
Address report to:
CC report to:
Video sent to:
Date Needed:
Your email address:
(Confirmation email will
be sent to this address)
ADJUSTER INFORMATION (Billing)
Name:
Company:
Address 1:
Address 2:
City:
 State:
 Zip:
Phone #:
 Fax #:
Claim #:
Email address:
PATIENT'S DOCTOR INFORMATION
Practice Name:
Doctor's Name:
Address 1:
Address 2:
City:
 State:
 Zip:
Phone #:
 Fax #:
Is there a script?:
(If YES, please fax)
PATIENT'S ATTORNEY INFORMATION
Firm Name:
Attorney:
Address:
City:
 State:
 Zip:
Phone #:
 Fax #:
EMPLOYER INFORMATION
Company:
Job Title:
Do you have a job
analysis?:(If YES, please fax)
ADDITIONAL INFORMATION
Please include any additional information, comments, or special
requests you would like addressed:
Your Industrial Solution
120 Valley Street
Tamaqua, PA 18252

Phone: 570.691.8986
Fax: 570.668.2691