Request Service

In order to request a certain type of assessment, evaluation or treatment, please use the form below or simply call us at (416) 255-0200 / (416) 826-2232, send us an email at omnisevaluations@rogers.com or send us a fax at (647) 576-2804.

Legal Representative

Service(s) Requested:

Vocational Assessment:

TMJ (Oral & Maxillofacial) Assessment:

Ophthalmological Assessment:

Sleep Health (Sleep Study) Assessment: Orthopedic Assessment: In-Home Assessment: Psychological Assessment: Assessment of Attendant Care Needs (Form 1): Chronic Pain Assessment: Social Assessment: Psychotherapy Counselling: Rehabilitation Clinic Injured Person Injured Person's Contact Information Last Name: Phone: Phone: Auto Insurance Company Information Name: Policy #: Claim #: AB Adjuster: Date of the Motor Vehicle Accident (mm/dd/yyyy): Email: Date of birth (mm/dd/yyyy): Address: First Name: Assistive Devices: Driving Anxiety Rehabilitation Therapy: Service(s) Requested by: Driving Assessment: EMG and Nerve Conduction Studies: Bone Scan Evaluation: Physiatry Assessment: MRI (Magnetic Resonance Imaging): Functional Ability Evaluation (FAE): Psycho-Educational Assessment: Cognitive (Intellectual) Memory, Executive Function and Personality Assessment: Psycho-Vocational Assessment: Neurological Assessment: Worksite Assessment (Physical Demands/Job Analysis): Activities of Daily Living Assessment: Name: Location: Rheumatological Assessment:

Omnis Evaluations Centre