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.

Request an IME

IME Request Form

General Information

Requestor Information

Claimant Information

Exam Information