WATERLOO 02 9319 5999 PARRAMATTA 02 8960 9133 OPINIONS & ASSESSMENTS 1300 1 IMMEX (46639) Online Booking Form Booking Form 1. I would like an appointment onDate* Date Format: DD slash MM slash YYYY OR the next available appointment Date Date Format: DD slash MM slash YYYY 2. LocationWhere would you like the appointment3. Specialty / ConsultantSpecialtyDoctor Name4. Claimant DetailsName*DOB* Date Format: DD slash MM slash YYYY Phone*Address Street Address Address Line 2 Suburb State Post Code 5. Type of ClaimTypePlease SelectCase Conference with Treating PractitionersFile ReviewInjury Management Consultation (IMC)MEDICAL EXAMINATION – Workers Compensation (IME)Medical Examination – CTPMedical Examination – Life and DisabilityMedical Examination – COMCAREFitness for Work AssessmentMedical Negligence ReviewPre Employment MedicalWhole Person Impairment (WPI) AssessmentWork VisitsOther6. Referrer DetailsName*Company*Ref/Claim No.*Type of Claim*Phone*Email* CAPTCHA This iframe contains the logic required to handle Ajax powered Gravity Forms.