IME Registration Form

Please correct the errors described below.

I understand that I have been sent to Northwest Rehabilitation Associates, Inc., the office of Daniel A. Brzusek, D.O., for an independent medical examination, and that all fees for this visit will be paid for by the requesting agency.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

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