Worker's Compensation Medical Certificate Reorder Form

To Submit your order fill out the form below and click submit

*fields marked with an * are necessary to process your enquiry

Contact Details

Name of person ordering:*

Email:*

Practice / Hospital Name:

Street Address:

Suburb:  Postcode:

Postal Address:

Suburb:  Postcode:

Phone: (no spaces)*   Fax:

Preferred Delivery Address: Please select... Street Postal

Practice Type: Please select... Doctor Dentist Nurse Practitioner

Order Quantity

Worker's compensation medical certificates come in pads of 50. Please order one pad per treatment room.

Please send (enter qty): pads

Please send (enter qty): single workers' compensation medical certificates (dentists only)

Please send (enter qty): Nurse Practitioner

Doctors Working at Practice

Please provide full names of each doctor working at this practice to help us maintain accurate records on our database.

Surname/Last Name	First Name	Other name/s

Registering Name (if applicable):

Service Period: to

Other Comments :

General enquiries about workers' compensation in Queensland
Call Q-COMP on 1300 789 881