Registration form
Medico-legal expert opinion

  In this initial phase, I prefer to submit my request anonymously and exchange
information only via e-mail.
  Optional personal data:
  Name:
  First Name: 
  Title: 
  Address:
  phone: 
  fax:
  e-mail: 
     
 

 

Compulsory data for initial evaluation procedure:
  Age:  
  Sex: f m  
 

Previous diseases:

Year: diagnosis (operation)
     
     
  Did you suffer a damage from surgery? yes  no 
    from other treatment? yes  no 
    from an accident? yes  no 
  If applicable, date of damage:
  Are all medical documents available? 
(patient record, x-rays, reports)		 yes  no 
   
  Name of attorney :
  Your opponent in a legal proceeding: 
     
  legal proceedings : not yet 
Underway since: 
Finished since : 
 

Other explanations:

 

 
     
 

 

Short description of events: Short description of consequences until today:

 
 

 

 

 

In case you can not send this form, please give us a call at (646)290-5085
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