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Your Name *

Your Company Name *

Your Reference *

Your Phone Number *

Your E-mail Address *

Type of Case *

Other *

Do you act for the Claimant or Defendant? *

Claimant

Defendant

Please provide Defendant details

Legal Firm Acting for Other Side

e.g. if you're acting for the Claimant, please advise us who is acting for the Defendant and vice versa.

Their reference

Claimant/Client’s Name *

Claimant/Client’s Date of Birth *

Claimant/Client’s Location *

Date of accident/ incident/negligence *

Primary Injury *

Other primary injury

Summary of accident/ incident/negligence

i.e., what happened/caused the injury

Summary of Claimant/Client’s medical condition(s)

i.e. what consequences/impact has the accident/injury had on the Claimant/Client

Upload Documents

e.g. Letter of Approach, Immediate Needs Assessment (INA)

Discipline of expert(s) required *

Other Discipline

Report deadline

When is your ideal month for assessment?

Can the Claimant/Client travel?

Yes

No

Can the Claimant/Client attend a remote assessment?

Yes

No

Preferred method of Assessment/Report?

In Person

Remote

Desktop

Approximate volume of documentation to review (pages) *

If not known, please provide comment in additional information.

Is the documentation paginated and a chronology drafted? *

Yes

No

Is this case funded by legal aid? *

Yes

No

Is your company able to make up the difference in hourly rates *

Yes

No

NRC Medical Experts do not work on legal aid rates.

Additional information

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NRC Medical Experts

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