Request an IME

IME Request Form

Complete this form and we will contact you within 1 business day to confirm the information and to provide you with a date and time for the IME. Thank you for your business! Your information is confidential.

General Information
Today's Date*
Requestor Information
Requestor's Name
First Last
Company*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Claimant Information
Claimant's Name
First Last
Claimant's Date of Birth*
MM slash DD slash YYYY
Date of Injury(s)*
Claim/File Number
Exam Information
Physician Requested
Reason for Exam*
- Worker's Comp
- Personal Injury
- No-fault
- Other
Additional Information
Please provide any additional information regarding a specific orthopedic specialty or physician you may require.
Timeframe
Email
This field is for validation purposes and should be left unchanged.

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Request an IME

IME Request Form

General Information

Requestor Information

Claimant Information

Exam Information