IME Request Form - Western Medical Assessments

CLIENT Information
Organization
Hidden
Job Position
Name
Last First
Address
Street Address City Province Postal Code
Direct Phone
Fax Number
Required Field

This email address will receive a copy of this submission.

Please complete this mandatory field to submit the assessment
Email*
Hidden
Source of Assessment Request
Hidden
Assessment Requested
For information about our commitment to protecting your privacy, please review our Privacy Policy.
CLAIMANT Information
CLAIMANT Information
Name
Last First
Address
Street Address City Province Postal Code
Main Phone
Alternate Phone
Email*
Occupation
Birth Date
Month
Day
Year
Interpreter Required
- Yes
- No
Gender
- Male
- Female
CASE Details
Description of Event
Date of Loss
Month
Day
Year
Is the claimant currently working?
- Yes
- No
Current Concerns
SCHEDULING
Please Choose a Service Required
What City is the service required to be performed in?
Specialist Requested
Claimant Email
Claimant Phone
Document Submission Options
1. Upload Files Here

How to Attach Files to Your Submission: Click "Select Files" and then browse for the documents you need to upload.
Upload Assessment File(s)
Drop files here or

Accepted file types: pdf, doc, jpg, png, Max. file size: 8 MB, Max. files: 5.

Terms and Conditions

1. A file opening fee may be charged to Client, to include but not limited to Medical Director’s fee; admin and/or clerical time; long distance and other disbursements.

2. Payment for services rendered is due upon receipt of invoice, net 30 days. Payments are to be addressed to Western Medical Assessments, 17204-106A Avenue, Edmonton, Alberta, T5S 1E6.

3. Any late cancellation (date will be stipulated in our letter with Appointment details) or no-show fee is the Client’s responsibility to cover, terms as in 2) above.

Online Request

CLIENT Information

Required Field

CLAIMANT Information

CLAIMANT Information

Birth Date

CASE Details

Date of Loss

SCHEDULING

Document Submission Options

1. Upload Files Here

How to Attach Files to Your Submission: Click "Select Files" and then browse for the documents you need to upload.

Terms and Conditions

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