IME Request

Expert Testimony Request

Please complete this form and we will call you/email you within 24 hours. Please call the office if you do not get contacted within 24 hours or you have any other questions. Thank you.
Claimants information:
Patient's Name*

First NameMiddle NameLast Name
Patient Date of Birth

MonthDayYear
Date
Date of injury [injuries]:*
Have you retained Dr. Hannani Before?

YESNO
Please List ALL body Parts being claimed
Firm you represent:
Firm's information; *
Attorney Name:

First NameLast Name
Phone Number

Area CodePhone Number
Email
example@example.com
Address

Employer Street Address

Street Address Line 2

Employer CityState / Province

Postal / Zip Code
Conflict of Interest Checkpoint (Completion of this section is required)
Has the claimant seen other orthopedic surgeons or had surgery; please list the name of doctors that have treated the patient .*
OPPOSING ATTORNEY INFORMATION [if patient is represented]
Attorney:

First NameLast Name
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name of individual completing this form

First NameLast Name
Email
example@example.com
Phone Number

Area CodePhone Number
Please verify that you are human*
Should be Empty:

Expert Testimony Request