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JurisSolutions logo: Expert Witnesses, Independent Medical Evaluations, IMEs, Expert witness directory, Expert Testimony, National Referrals, Database Search. Space next to logo, medical experts and physicians join our online referral directory database. Home: Expert Witnesses for testimony and Independent Medical Exams, IMEs; referral directory Expert Witness information on testimony and our services. Faq about medical expert referrals and how to join our online database.
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Spacer: online join form for medical expert referral database. EXPERT WITNESSES AND INDEPENDENT MEDICAL EVALUATIONS

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CONTACT

Last Name:    First Name:  
Title:

Practice Focus: 
Address:
City:   State: 
Zip:   County:
Specialty:
Sub-Specialty:


Contact Last Name:  
Contact First Name:  
Email:
Phone 1: (xxx)xxx-xxxx  
Phone 2 : (xxx)xxx-xxxx 
Fax : (xxx)xxx-xxxx


LOCATION
(If you have additional locations, other than your address above please enter below)
Address
City
State
County
Zip
Location 1:
Location 2:
Location 3:
Location 4:
Location 5:
Location 6:
Location 7:
Location 8:


PROFILE

Years in practice: 
Board Certified?     yes    no
Board Eligible?       yes    no
Name of Board 1:
Date Admitted 1:
Name of Board 2:
Date Admitted 2:
Social Security Number:
License Number:
Federal ID Num.:
WCB Code:
WCB Num:

INFORMATION
Medical School Location
Degree Year
Internship Hospital Year
Residency Hospital Year
Fellowship Year
  
ADVERSE ACTIONS
(If you answer "Yes" to any of the following, please give an explanation below)
1. Is your license in New York or any other state currently under investigation?
yes    no
2. Has your narcotics license in New York or any other state ever been revoked, suspended or relinquished to avoid such action?
yes    no
3. Have your privileges at any hospital ever been limited, revoked or suspended?
yes    no
4. Has your membership in the medical staff of any hospital ever been revoked or voluntarily surrendered to avoid such action?
yes    no
5. Has your membership in any professional society ever been revoked or voluntarily surrendered to avoid such action?
yes    no
6. Have you ever been censored or reprimanded by a professional society?
yes    no
7. Have you ever been convicted of a felony or misdemeanor?
yes    no
8. Have there been any sexual misconduct charges brought against you?
yes    no
9. Have you ever been the defendant in a malpractice case?
yes    no

Add a two to three sentence statment about your practice, qualifications, or experience)...

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