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Requestor Information
  First Name: (required)
  Last Name: (required)
  Street Address 1:
  Street Address 2:
  City:
  State:
  Zip Code:
  Phone: (required - numbers only)
  Fax: (numbers only)
  Email Address: (required)
  Claim #:
  WC #:
  Date of Injury:
  Type of Case:
  Service:
  Do you have a specific deadline for the completed report?

Does the billing information differ from above? Yes No
Do you have the Examinee's information? Yes No
Do you have the Attorney's information? Yes No
Do you have the Treating Doctor's information? Yes No

Requested Specialty(ies) or Examiner(s):

Injuries/Conditions to be Evaluated:

Specific Issues or Concerns:

Record Information
  Medical Records to be Provided By*:
  Approximate Volume in Inches:
  X-rays to be Provided By:
* We are happy to pick up or copy your file if necessary

 

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