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 Medical Diagnostic Services - Independent Medical Panel Examinations
Online Service Request

 

To expedite service, simply complete and submit this form. An MDS scheduler will contact you as soon as possible to confirm the location and time of appointment.

All information is secure and strictly confidential. The brief details provided allow us to assign the patient to the most appropriate examining Physician.

   Service Request

Select Preferred Office Location:

Enter Approximate Date: Time:

Enter Patient Information:
 
  Name:
  Address:
  City: State: Zip:
 
  Phone Number: Claim Number:
  Date of Injury: Type of Injury:

Enter Referral Information:
 
 Name:
 Title:
 Company:
  Address:
  City: State: Zip:
 
  Phone:   Fax:

Select Type of Services Requested: (You can select multiple items.)
 
 

Request Addendum To:
 
  Patients Name: Date of Service:

  Information Needed:
 
 

Specific Specialties or Examiners Requested:
 
 

Other Services Needed:

  Travel Arrangements:
 
 

  Hotel:
 
 

  Ground Transportation:
 
 

  Bill for Travel:
 
 

  Copy of Report to:
 
 

Enter Billing Information: (If Different than referral above)
 
  Name:
  Title:
  Company:
  Address:
  City: State: Zip:
  Phone: Fax:

Special Instructions or Services Needed:
 
 

Enter Your Email Address:
 
Enter Your Real Name:
 
 
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