Independent Medical Exam

Your role in this request*

Please select your role on this request

Your Name*
Please type your name.

Your Email*
Invalid Email Address

Your Phone Number*
Please enter a valid phone number

Estimated number of records in pages*
Please select estimated number of records in pages

Upload records here
Invalid Input

Worker Compensation Insurance Company*
Please enter Worker Compensation Insurance Company

Worker Compensation Insurance Company phone number
Please enter a valid phone number

Adjuster name
Invalid Input

Case manager name
Invalid Input

Patient First Name*
Please type Patient First name.

Patient Last Name*
Please enter Patient Last Name

Patient Phone Number*
Please enter a valid phone number

Street Address*
Please enter your street address

Street Address
Invalid Input

Please enter your city

Please select a state

ZIP Code*
Please enter your ZIP code

Patient Date of Birth*
Please enter Patient date of birth

For which of the following is your client seeking an examination?*

Please enter the type of examination you seek

What is the reason for your client’s visit?
Please enter valid reason of your visit

When did this injury occur?*
Please enter date when you injury occur

Which of the following was the cause of this injury?

Invalid Input

Please specify the cause of the injury*
Invalid Input

What is your client’s preferred appointment location?

Security Validation
Invalid Input

1 of 1
You are using an unsupported version of Internet Explorer. To ensure security, performance, and full functionality, please upgrade to an up-to-date browser.