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You Represent:
Your Client:
Your Sector:
What state jurisdiction is the claim under?
Assessment Type:
Specialty Required:
(You may choose 1 or more related specialty type, e.g., Orthopaedic Surgeon and Musculoskeletal Physician)
Other Specialty:
Pain Management
Pain Medicine, Rehabilitation Medicine
Pain Specialist
Specific Area of Expertise:
Telehealth:
Will this be a Telehealth appointment?
Yes
No
Select the time zone of the injured person.
[Unassigned]
Sydney, Canberra, Melbourne
Brisbane
Perth
Adelaide
Darwin
Hobart
Attendee's Postcode:
Postcode:
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From
To
We have found a list below of available times.
Max distance (km):
All
We have found a list below of medical experts.
Booking Summary
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Email
*
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Password
*
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Password (confirm)
*
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Title
*
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First Name
*
Please enter First Name
Last Name
*
Please enter Last Name
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Verification Code (4 digits):
Mobile
Referrer Email
Email
*
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Organisation
Select an organisation from the dropdown list
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Organisation Name
*
Division or Branch (if applicable):
Central Contact Number (if applicable):
Your Phone No.
*
Please enter your Phone No.
Your Mobile No.
Central Email Address For All Reports
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Email
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Password
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Referral Letter and Supporting Documentation:
(Please note you may upload these at a later time)
Drag Drop your files
Drag and drop documents here.
Other Attachments:
Drag Drop your files
Drag and drop documents here.
Referral Details:
Claim/Injured Person Details
Title:
*
Please enter Title
First Name:
*
Please enter First Name
Last Name:
*
Please enter Last Name
Mobile:
*
Please enter Mobile
Email Address:
required for Telehealth
Date of Birth:
*
Please enter Date of Birth
Claimant's Employer Details
Claimant's Employer Name:
*
Please enter Company Name
Claimant's Employer Address:
Case Details:
Claim No. / Ref. No.:
*
Please enter Claim No.
Date of Injury:
*
Please enter Date of Injury
WiRO ILARS Number (if relevant):
Injury Type:
Physical
Non Physical
Interpreter Required:
Arrange interpreter through Ezispeak
MEDirect’s preferred Interpreter service is Ezispeak. Interpreting services are conducted via video conferencing or in-person. For in-person assessments, if an interpreter is not able to attend, then a phone service will be offered.
MEDirect will provide all relevant referral details and your billing details to Ezispeak, and they will invoice you directly for this service.
MEDirect will provide confirmation of the scheduled service once it has been arranged.
State the language needed:
Urgent Report:
Date Report is Due:
Comments in relation to this booking, if required:
Is the report to be addressed to you?
Yes
No
Referrer Title:
*
Please enter Referrer Title
Referrer First Name:
*
Please enter Referrer First Name
Referrer Last Name:
*
Please enter Referrer Last Name
Referrer Email:
*
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Is the Medical Expert required to speak directly with the Treating Health Practitioners, employers or others, for this referral?
Yes
No
Add the details of any Treating Health Practitioners, employers or others, that need to be contacted as part of this referral
Name
Role
Phone
Email
Category
Action
Add Contact
Title
First Name
Last Name
Contact Category
Treating Health Practitioner
Employer
Other
Role
Phone
Email
Invoice Details:
Select invoice details from the dropdown list
Add new invoice details
Invoice Details
Legal Name
ABN
Division
Address
Address Line 1
Address Line 2
City
State
Postcode
Email (to send invoice)
Phone number (for enquiries)
Report Dispatch:
Securely upload from MEDirect platform only
Send to my email address
Send to alternative email address
Send to central email address
Booking Completed!
Thank you! Your booking has been confirmed!
Appointments Available on Request
Please complete the form below to request a specific appointment time with your chosen Medical Expert.
Please note, this appointment has not yet been confirmed.
The MEDirect Bookings Team will be in touch shortly to discuss your request.
Is this Urgent?
*
Yes
No
What is your preferred date range for the appt?
*
After
Before
What time works best?
*
Morning
Afternoon
Anytime
Claimant Name or Claim No
*
You Represent
Your Sector & State jurisdiction
Preferred Time
Assessment Type
Telehealth Appt?
Please include any specific requirements for this appointment
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