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About TSR
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Services
• Functional Abilities Evaluations
• Independent Medical Evaluations
• Work Analysis
• Ergonomic Evaluations
• Transferable Skills Analysis
• Occupational Therapy Home Assessments
• Work Hardening Programs
• Non-Dominant Hand Training
• Rehabilitation Services
• Workplace Health & Safety Programs
• Occupational Therapy File
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Referral Form
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The Oshawa Health Centre


Please complete the Patient Referral Form below and click the SUBMIT button at the bottom. All data entered in the Patient Referral Form are through an SSL (Secured Socket Layer) connection thereby protecting the confidentiality of your data.

TSR Referral Form
Patient Information
Patient Name
Address
City
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Country
Postal Code
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Date of Birth - -
Impairment/Diagnosis
Legal Representive
Legal Contact
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Employer Contact
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Patient’s Occupation
 
Refferal Information
Company
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Date of Refferal
Address
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Assessments Required 1, 2, 3, 4, 5 Day Functional Ability Evaluation with work or home analysis
1, 2, 3, 4, 5 Day Functional Ability Evaluation without work or home analysis
Cognitive Functional Ability Evaluation
Ergonomic assessment of work station
Work Site assessment
OT Home assessment
Work Conditioning/Hardening
Transferable Skills Analysis
IME (specialist):
Treatment (type):
Other:
Special Instructions
Assessment Mandate
Assessment Location

Oshawa
North York
Mississauga
Waterloo
London
Belleville
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