Please select which location you are submitting this form to:

First Name: *
Last Name: *

Phone (Day): *

Phone (Evening):

Address: *

City: *
Province: *
Postal Code: *

Your Email: *

Date of Birth: *

Occupation: *

Alberta Health Care (AHC) Number:

SIN (Only if no AHC #):

Claim Number: *

Please check this box, if you have not yet been assigned a claim number by WCB.


Accident Details

Date of Accident: *

Name of the Doctor seen about the accident:

Referral Date:

Family Doctor's Name:

Describe the work related injury (how and where):


Employer Details

Employer's Name: *

Employer's Phone Number: *

Employer's Address: *

City: *
Province: *
Postal Code: *

Supervisor's Name: *

Supervisor's Phone Number: *


Current Work Status *

Off Work
Working
Modified (Specify which level below)
Sedentary Lifting (10 lbs Maximum)
Light Lifting (20 lbs Maximum)
Medium Lifting (50 lbs Maximum)
Heavy Lifting (100 lbs Maximum)
Very Heavy Lifting (Over 100 lbs)

Before your injury what was your normal work level? *


How Did You Hear About Us?

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We require a minimum of 24 hours notice for a cancellation or a cancellation fee will apply.

The Workers' Compensation Board does not automatically approve all claims submitted to them. If your WCB claim is rejected then you are responsible for the cost of any physiotherapy treatments you have received. The cost per visit is $105.00.

I have read and understood the above information. *
Date