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WORK RELATED INJURY CONSULT PATIENT HISTORY Todays Date:___ TELL US ABOUT YOU: Name: ___ Birth Date: ___ Age:___ Male Female Address:___ City: ___ State: ___ Zip: ___ Email Address: ___ Phone#: Cell/Home
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How to fill out work related injury consult

01
Start by gathering personal details: Name, address, phone number, date of birth.
02
Include employment information: Employer's name, address, job title, and employment start date.
03
Describe the injury: Specify the type of injury, date it occurred, and how it happened.
04
Document medical treatment: List any medical professionals visited and treatments received.
05
Explain the impact: Detail how the injury affects your ability to work and daily activities.
06
Review the form for completeness: Ensure all sections are filled out accurately.
07
Submit the consult form to the designated authority.

Who needs work related injury consult?

01
Employees who have sustained a work-related injury.
02
Workers seeking medical treatment or assessment for their injuries.
03
Individuals needing documentation for insurance or legal purposes regarding work injuries.
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A work related injury consult is a formal process where an employee discusses and evaluates an injury sustained at work, often involving healthcare providers and employer representatives to determine the nature and extent of the injury and appropriate treatment.
Typically, any employee who has sustained a work-related injury is required to file a work related injury consult, along with their employer or designated representative.
To fill out a work related injury consult, the employee must provide detailed information about the injury, including how and when it occurred, any symptoms experienced, and initial treatments received, along with relevant personal and employment information.
The purpose of work related injury consult is to document the injury, facilitate appropriate medical care, ensure compliance with workplace safety regulations, and to initiate any necessary claims for worker's compensation.
Information that must be reported on a work related injury consult includes the employee's name, job title, details of the injury, date and time of occurrence, witnesses, and any treatments received.
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