Online Request Form

CLIENT INFORMATION
Law Firm/Facility*
First Name*
Last Name*
Position*
City*
Province*
Direct Phone*
Email*
Send me an email copy of this request
- Send me an email copy of this request
Representing:*
- Plaintiff
- Defence
CASE DETAILS
Date of Loss*
Date Format: DD slash MM slash YYYY
Concerns*
STANDARD of CARE
Expert Requested*
Concerning actions of:*
- Physican
- Nurse
- Psychologist
- Dentist
- Chiropractor
- Other
SENDING DOCUMENTS?

Send documents to: info@medmaldoctors.ca
DATE of REQUEST
Date of Request*
Date Format: DD slash MM slash YYYY
TERMS and CONDITIONS
Payment for services rendered is due upon receipt of invoice, net 30 days.

See the website for additional Disclaimer, Terms of Service and Privacy Policy.
CAPTCHA