SECURE ONLINE SCHEDULING

Use our HIPAA compliant online Scheduling Request Form to get your case on the schedule faster. For additional assistance or doctor information, contact our experienced Scheduling Team by email, or call us at 1-800-261-FAST (3278).

Note: Fields with an asterisk(*) are required.

Your Contact Information

First Name:*	Last Name:*
Company:
Phone:*	Fax:
Mailing Address 1:	Mailing Address 2:
City:	State:
Zip Code:	Email:*

Claimant Information

Diagnosis/Type of Injury:*	Claim Jurisdiction:*
File/Claim Number:*	Date Of Injury:*
Claimant Name:*	Date Of Birth:*
Claimant Gender* Male Female
Phone Number:
Mailing Address 1:	Mailing Address 2:
City:	State:
Zip Code:*
Treating Doctor:	Employer:
Would you like us to mail a confirmation letter to the claimant?* Yes No (by choosing "Yes" you MUST provide a mailing address in the above field.)
Would you like us to call the claimant 3 days prior to the IME?* Yes No (by choosing "Yes" you MUST provide a phone number in the above field.)

Service Information

Service Type:*	Case Type:*	Timeframe You'd Like IME Scheduled:*
Doctor and/or Specialty Preference:* (If you are not sure which doctor to use please type "contact me" above. To request doctor listings or calendars, click here.)
Please Tell Us About Any Scheduling Constraints, Report Deadlines, and/or Additional Contacts On This Case:
How would you prefer we notify you of the scheduled appointment?*
How did you hear about us?