Referral to SalusWA
Simply let us know what services you need and we will make the necessary arrangements and one of our staff will be in touch within 24 hours.
Referrer's Details
Please provide your details so we can get in touch
Your Name *
Your answer
Your Email *
Your answer
Your Phone Number *
Your answer
Your Relationship to the Worker *
Worker's Details
Please provide details of the injured worker below
Worker's Name *
Your answer
Worker's Date of Birth
MM
/
DD
/
YYYY
Worker's Address
Your answer
Worker's Phone Number
Your answer
Worker's Email
Your answer
Comments regarding injury/illness and assistance required
Your answer
Other Contact Details
Doctor's Name
Your answer
Employer Company Name
Your answer
Employer Contact Name & Number
Your answer
Insurer & Claim no
Your answer
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