GARLAND & ASSOCIATES

California Workers' Compensation

Medical Evaluations and Treatment

INDEPENDENT MEDICAL EXAMINATIONS 

 

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 Please fill out the following form and we will contact you as soon as possible  (Usually within 1 hour or less)

If you have any questions, please give us a call at 888 455-1600 or click here to send us an email

 

Examiner Email / Attorney Email  / Assistant email  who is scheduling appointment  

Examiner / Attorney / Assistant Phone # who is scheduling appointment                     

 

Type of Evaluation        

How soon you want the Appointment to be scheduled ?               

 

Please select the Doctor from the following for Orthopedic

 

 

Please select the Doctor from the following for Internal Medicine

 

Please select the Doctor from Industrial Medical Evaluators - Multi Specialty

 

Please select the Doctor from the following for Ophthalmology

 

lease select the Doctor from the following for Urology

 

Please select the Doctor from the following for Chronic Pain

 

Please select the Doctor from the following for Ear Nose and Throat - TMJ and Plastic Surgery

 

Please select the Doctor from the following for Neurology

 

Please select the Doctor from the following for Psychiatry, Psychology and Neuropsychology

   

    Claimant Name                                     

    Claimant Address                                 

    Claimant Phone Number                      

    Claimant date of birth                           

    Claim #                                                   

    Date of Injury                                          

    Type of Injury                                          

    Employer                                               

    Interpreter needed ?                                            

     If yes, who will schedule interpreter     

    Claims Examiner Name                        

    Claims Examiner Phone                                                           Fax

    Insurance Name                                     

    Insurance Address                                 

    Will you be sending cover letter ?           

    Will you be sending Medical Records ? 

    Defense Attorney Name and Law Firm Name  

    Defense Attorney Address                     

    Defense Attorney Phone #                        Fax

    Applicant Attorney Name                        

    Applicant Attorney Address                    

    Applicant Attorney Phone #                       Fax 

    Comments                                                

               

 

Last update on 03/05/2014