Online Scheduling

APPOINTMENT REQUEST FORM

So that we can efficiently process your request, please complete the following...

If you would prefer to print out a blank form and then fill it out to fax, please click here.

Use the "Tab" button to jump from field to field. Note that hitting "Enter" will submit the form.

Exam Type

Case Type

Workers' Compensation

Personal Injury

Long Term Disability

Patient Information

First Name
Last Name
Middle Initial
Gender
Social Security #
Date of Birth	//
Home Address

City
State
Zip
Home Phone
Date of Injury
Claim/File #
Type of Injury/Diagnosis
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 1 business day prior to the scheduled IME?
Would you like a confirmation letter and directions to the above examinee?
Would you like a map of IME location sent with initial confirmation?
Background Information (Optional)

Workers' Compensation ONLY

Employer
Title/Occupation of Injured
Date Hired
Does the IME Physician have permission to perform functional testing (FCE) if needed?

Referred/Submitted By *please note this will be the contact we respond back to

Please send invoice to...

The Assessment Centers

General Scheduling 1-888-676-3212

Fax (502) 568-6867

Springs Office Building, Suite 210

950 Breckenridge Ln

Louisville, KY 40207

Phone (502) 587-0023

Beaumont Center, Suite 206

1030 Monarch St

Lexington, KY 40513