Tri Rivers Consulting Request/Schedule a Service UR/Peer Reviews Our Physicians Locations Contact Tri Rivers
To request a medical-legal service from Tri Rivers, please complete and submit the form below, using your “tab” key to move between fields. Once we receive your request, a member of our staff will contact you for additional information, if necessary, and to confirm the appointment. Note: This is a secure website.
  Independent Medical Evaluation (IME)
  IME Concussion/Head Injury
  Independent Medical Re-Evaluation
  Impairment Rating Evaluation
  Record Review
  Oral Deposition
  Video Deposition
  Other Service, Please Describe:
Please provide the requested information about you and your company
Your Name: 
Your Company's Name: 
Address: 
City: 
State:  Zip: 
Phone Number:  (
Fax Number:  (
E-mail Address: 


Once the service is scheduled, do you prefer to be notified by:
To whom would you like the report addressed to?
Same as Contact Information
Name: 
Company's Name: 
Address: 
City: 
State:  Zip: 
Phone Number:  (
Fax Number:  (
E-mail Address: 
To whom would you like the report mailed to?
Same as Contact Information
Name: 
Company's Name: 
Address: 
City: 
State:  Zip: 
Phone Number:  (
Fax Number:  (
E-mail Address: 
To whom would you like the report billed to?
Same as Contact Information
Name: 
Company's Name: 
Address: 
City: 
State:  Zip: 
Phone Number:  (
Fax Number:  (
E-mail Address: 
Please provide the requested information about the case/claimant you are scheduling.
Name:
Claimant/File Number: 
Social Security #: 
Address: 
City: 
State:  Zip: 
Phone Number:  (
Birthdate: 
Employer: 
Occupation: 
Date of Injury: 
Can we take x-rays? 
Type of Injury: 
Please provide a
brief description of the
injury including body
part(s) affected:

I would like to schedule this service with a board certified specialist in:

  Orthopedic Surgery
First Choice

Second Choice

  Physical Medicine and Rehabilitation

  Neurosurgery

  Neurology

  General Surgery

  Oral & Maxillofacial Surgery

  Rheumatology

  Internal Medicine

  Concussion

 Preferred Office Location

 Which is most important to you


Please use this space to let us know of any particular needs relating to
this case, such as deadlines, unusual circumstances, etc.

clear form
 
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