Occupational / Forensic Evaluation Request
(IME • Fit-for-Duty • Forensic)

What type of evaluation are you requesting?

Other (If Applicable)

Organization / Firm Name

First name

Last name

Phone

Who is the evaluation for?

Subject/examinee name (optional if confidentiality needed at this stage)

Subject/examinee age and/or DOB (optional)

Primary concern / reason for referral

Industry/role (if occupational)

Is there current litigation or an open claim?

Yes

If yes, please provide claim/case number and jurisdiction

What specific questions do you need answered in the report?

Do you have a deadline?

Preferred timeframe for scheduling

Will you be providing records for review?

Yes

If yes, please list what will be provided (medical records, job description, depositions, etc.)

Upload records

Preferred evaluation format

Location preference

Who will be financially responsible?

Best person to contact for contracting/payment (name + email)

Best method/time to reach you

Anything else we should know?