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InMedical, Inc.    
405 North Calhoun Road    
Suite 107    
Brookfield, WI 53005    
Tel: 262-785-1510    
Fax: 262-785-8009    
IME: 877-785-1510    
info@inmedical.com    		   Schedule an IME

USE THIS FORM TO SCHEDULE YOUR INDEPENDENT MEDICAL EVALUATION

Client Information

Client's Name 
Client's Title 
Client's Company 
Client's Company Address 

Client's Phone 
Client's Fax 
Client's Email Address 

Examinee Information

First Name 
Last Name 
Address 
City, State, Zip 
Phone 
Date of Birth 
SSN 

Case Information

Exam Type  IME   Record Review   Functional Capacity Evaluation
  Deposition   Addendum   Permanent Partial Disability Evaluations
  Fitness For Duty    Bio Mechanical Evaluation
  Legal Nurse Case Consulting
  Diagnostic Film Interpretation   

Case Type

  Worker's Comp.   Personal Injury   Disability   No-fault
  Other 

Details

Date of Injury 
Claim / File Number 
Type of Injury / Diagnosis 
Treating Physician 
Specialty Requested 
Doctor Requested 
We can suggest or you can select 
from our Physician Finder 
(login and password required). 
Location Requested 
When do you need this IME by? 
Does the patient have an attorney? 
Name of Attorney 
Attorney Phone 
Attorney Address 

Would you like a confirmation call to 
the examinee 4 business days prior 
to the scheduled IME? 		 Yes   No
Would you like a confirmation 
letter and directions to the 
above examinee? 		 Yes   No
Would you like a map of IME location 
sent with initial confirmation? 		 Yes   No
Background Information (Optional) 

Cover Letter Questions (Optional)

Please mark the questions you would like the consultant to address.
  1. Is the condition directly related to the incident in question? Please explain why or
           why not.

  2. Did the injury precipitate, aggravate, or accelerate a pre-existing or deteriorating
           condition beyond normal progression? If so, please explain.

  3. Did the incident cause a temporary aggravation of a pre-existing condition? If so,
           please explain.

  4. Were the symptoms complained of a mere manifestation of a pre-existing
           deteriorating condition? If so, please explain.

  5. Was an appreciable period of workplace exposure the sole cause or at least a
           material contributory, causative factor in the conditions onset or progression?

  6. Is further medical treatment needed? If so, please explain.

  7. Has all treatment been related to injuries sustained on the date of accident?
           Please be as specific as possible, and please explain why or why not.

  8. Of the treatment related to the injury, what appears appropriate and necessary?
           Please be as specific as possible, and please explain why or why not.

  9. Has the claimant reached an end of healing? If so, when did the claimant reach
           an end of healing? If not, when do you anticipate the claimant will reach an end of
           healing?

  10. Can the claimant return to work? If the claimant cannot return to work, when do
             you anticipate a return to work?

  11. Do you feel the claimant should have any restrictions? If so, please specify what
             they are, how long they should remain in effect, and if they are related to the
             incident in question.

  12. Has the claimant suffered any permanent partial disability as a direct result of
             the injury? If so, please state a percentage based on the appropriate guidelines.

Additional Comments 

If you do not receive a response to this form within 24 hours, please call 1-877-785-1510.

  

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