Work Cover Form "*" indicates required fieldsName* Mr.Mrs.MissMs.Dr. Prefix First Last D.O.B*Insurance DetailsIs your claim with WorkCover QLD?* Yes NoIs your claim with another insurer?*e.g self insured companies Yes NoInsurer Name (if not Workcover Qld):Claim Number (if known):Injury DetailsInjury Date:*Injury Details:*Have you been seen by any other doctors or Hospitals for this Injury?* Yes NoIf Yes, by Who & Where :Insurance Claim ManagerClaim Manager Name (if known): First Last PhoneEmailEmployerEmployers Name:*Employer Phone:*Email:Employer Address Street Address Suburb Post code Financial AcknowledgementAll initial Workcover appointments will be billed as a standard consult. This can then be claimed back from Workcover once the claim is approved. If the claim is rejected by Workcover for whatever reason the costs of the initial appointment and any further treatment you undertake through our practice will be your responsibility.Please tick to acknowledge that you have read and accepted this condition of treatment.* Please tick to acknowledge that you have read and accepted this condition of treatment.SignatureDate MM slash DD slash YYYY CAPTCHACommentsThis field is for validation purposes and should be left unchanged.