independent medical evaluation

law firms & other organizations

For all IME requests, please complete the form below and we will aim to respond within 72-hours.

Independent Medical Evaluation Request

Name of Company or Law Firm

Office Location

Name of Person Booking

First Name

Last Name

Telephone of Person Booking

Email of Person Booking

Name of Client (to be assessed)

First Name

Last Name

DOB / Age of Client

What is the nature of the matter?

Other (please specify the nature of the matter below):

Location for Appointment

Other (please specify your preferred location below):

Date of Appointment Requested

Other (MM/YYYY):

Preferred time of appointment (am / pm / any)

Additional Info