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Date:
Claim #:
Date of Injury :

Insured/Defendant:

Type of Case :

Examinee prev. examined by us? (date)

Testing to Date:

Plaintiff/Examinee::

Address: (street)

(city, state, zip)

Phone:

Plaintiff/Examinee's Attorney:

Address: (street)

(city, state, zip)

Phone:

Contact Examinee Directly
Attorney Only

Venue:

Prior or Subsequent Conditions/Injuries:

Treating Physician:


Medical Specialty:
  Orthopedist   PM&R   Dentist   ENT
  Neurologist   Internist   TMJ   Radiologist
  Psychiatrist   Chiropractor   Plastic Surgeon
Other :

Physician is pre-authorized to perform x-rays or other testing
in conjunction with this exam?
yes no    specify: 

Issues to be Addressed:
Causal Relation Return to Work/ADL Schedule Loss Eval. (Comp.)
Degree of Disability Permanence Apportionment (Comp.)
Need for Treatment/Testing Need for Surgery M&S Issues (Comp.)

Specific Issues to Address and Instructions:
(Please describe details of this referral and any issues of case)

Client Law Firm/Insurance Co:

Address: (street)

(city, state, zip)

Contact : (Requested by:)

Phone:

Attorney :

Phone :

Billing Address if Different:
Address: (street)

(city, state, zip)

Contact :

Phone:

Your Email: (Requested by:)

(For email confirmation of this request - separate multiple emails with commas)


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