Solicitor Case Referral Form

Solicitors New Referral Form

Your Details
Injured Person Details
Defendant Details (If Known)

YOUR DETAILS

Referrer Name

Company Name

Telephone Number (DDI)

Your Reference

Case Type

Liability Status

INJURED PERSON'S DETAILS

Injured Person's Name

Date of Birth

Gender

Incident Date

Incident Details

Injury Details

Upload Supporting Documents

Choose File

Upload Supporting Documents

Choose File

DEFENDANT DETAILS (If Known)

Defendant Contact Name

Company Name

Address Details

Contact Telephone

Contact Email

Defendant Reference

Any other relevant information you'd like us to know at this stage?

Privacy & Data Protection Notice
The information you submit via this form, including any sensitive personal or medical data, will be handled securely and confidentially in accordance with the UK General Data Protection Regulation (UK GDPR) and Data Protection Act 2018.

We collect this information solely for the purpose of assessing and arranging appropriate rehabilitation services. Access is restricted to authorised Medicess staff only.

By submitting this form you confirm that you have the necessary authority and consent to share this information with us, and that you understand it will be processed in line with our Privacy Policy

Solicitor Case Referral Form

YOUR DETAILS

INJURED PERSON'S DETAILS

DEFENDANT DETAILS (If Known)

Medicess

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