Referral

Welcome to DP Workplace Solutions. Thank you for submitting this request for service. One of our team will be in contact very soon to discuss this service request with you. Work performed for ReturnToWorkSA workers compensation claims will be completed by DP Workplace Solutions (SA) Pty Ltd

Submit a Referral

Please select the service you are querying about:*
Preferred Consultant (if applicable):
Referrer contact details:
Name:*
Organisation:*
Phone:*
Fax:
Email:*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Preferred contact method:
- Email
- Phone
Preferred contact time:

: HH

MM
Referral source:
- Workers Compensation
- Comcare
- Third Party Insurance
- Self Insured
- Other
Employee Details
Name:
First Last
Birth Date:
Date Format: MM slash DD slash YYYY
Injury Type:
Date of Injury:
Date Format: MM slash DD slash YYYY
Occupation:
Phone Number:
Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Upload a File:
Email
This field is for validation purposes and should be left unchanged.

Submit a Referral

Referrer contact details:

Employee Details

Submit a Referral

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