Medical Evaluation Appointment Form

Thank you for reaching out to TriMedical. To secure a booking, we will need addtional information. All information provided is strictly confidential.

Name

First Name

Last Name

Address - Street, City/Town

Date of Birth

MM

DD

YYYY

Gender at Birth

Male

Female

Prefer not to say

Personal Health Number

Date of Injury/Accident

MM

DD

YYYY

ICBC Claim Number

#102 - 12565 88th Avenue
Surrey, BC, V3W 3J7
Canada

Toll-free: (236) 862-2126