Medical Legal Request Form

Request Type (select from menu) 🡳 *

Please complete the information below to request medical legal services.

Is this a Subpoenaed Request? *

Yes
No

Is this a work related injury? *

Yes
No

Medical Expert Requested (select from menu) 🡳

Name *

First

Last

Firm/Company Name *

Firm/Company Address *

Requestor Email *

Requestor phone *

Case Name *

Case Type *

(Personal Injury, Labor & Employment, Product Liability, etc.)

Claimant/Plaintiff Name *

First

Last

Claimant/Plaintiff DOB *

Opposing Counsel

Claimed Injuries *

Timeframe Needed

Additional instructions/Information

Thank you for your interest in working with our Medical Experts. A member of our team will contact you within 24 hours of receipt. Your request is of the utmost importance to us and we shall keep your information confidential. Please be advised that your request does not guarantee our acceptance of this case, nor can the assumption be made that we are actively working on this matter until a member of our team contacts you. By clicking on submit you agree to these terms.

Locations

(707) 546-1922

Locations