VERA Account Request

Welcome to Vera Medical

By opening a VERA Account, you will have full access to all of our resources including videos, presentations, eBooks, articles, reports and other learning materials.

Client Information

Organization

Last Name

First Name

Street Address

City

Province

Postal Code

Direct Phone

Fax Number

Email This email address will receive a copy of this submission.

Claimant Information

Last Name

First Name

Street Address

City

Province

Postal Code

Main Phone

Alternate Phone

Occupation

Birth Date

Interpreter Required

Yes No

Gender

Male Female

Case Details

Description of Event

Date of Loss

Is the claimant currently working?

Yes No

Current Concerns

Scheduling

Please Choose a Service Required

Specialist Requested

Claimant Email

Claimant Phone

Document Submission Options

Upload Assessment Files - Click "Select Files" and then browse for the documents you need to upload.

Drop files here or click to select

Accepted file types: PDF, DOC, JPG, PNG | Max file size: 8 MB | Max files: 5

Terms and Conditions

A file opening fee may be charged to Client, to include but not limited to Medical Director's fee; admin and/or clerical time; long distance and other disbursements.
Payment for services rendered is due upon receipt of invoice, net 30 days. Payments are to be addressed to Vera Medical, PO Box 66477 RPO Hollick Kenyon, Edmonton AB, T5Y 0M5.
Any late cancellation (date will be stipulated in our letter with Appointment details) or no-show fee is the Client's responsibility to cover, terms as in 2) above.

Problems filling in the form? Call: 1-587-984-8372

Contact Information

Please call our team to discuss any assessment
issue without obligation.

PO Box 66477
RPO Hollick Kenyon
Edmonton AB T5Y 0M5

Phone: 1-587-984-8372

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