IME Registration Form

Patient's Name

Date

Address

City

State

Zip Code

Home Phone

Date of Birth

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.

Patient's Name

Date

Parent’s Signature if Minor

Date

Advised by attorney to NOT fill out any additional forms

Your information will be encrypted.