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Your Name *

Your Company Name *

Your Reference *

Your Phone Number *

Your E-mail Address *

Do you act for Claimant or Defendant? *

Claimant

Defendant

If defendant, please provide their details *

Legal Firm Acting for Other Side *

Their reference *

Claimant/Client’s Name *

Claimant/Client’s Date of Birth *

Claimant/Client’s Location *

Date of accident/incident/negligence *

Summary of accident/incident/negligence *

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

Upload Documents

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

Other

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 *

Is the documentation paginated?  *

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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