Medical Legal Request Form

Please complete the form below. Our Client Manager will reach out to you to schedule an appointment.

All information provided is strictly confidential.

Name

First Name

Last Name

Please indicate reason for appointment

IME - Independent Medical Exam

FCE - Functional Capacity Evaluation

CPP - Disability Medical Examination

Medical Report

Medical Services for Insurers

Other, please indicate below

Additional Information, if applicable

Phone Number

Email Address

Our Office LOCATION

#102 - 12565 88th Avenue
Surrey, BC, V3W 3J7
Canada

Toll-free: (236) 862-2126