Expert Consultant’s
Information Form
MedicoLegal
Consultants
11041 Santa Monica
Boulevard #719
Los Angeles, CA 90025-3523
Print out and complete this form and send
to us with CV (unless sent) and registration fee ($100)
Please print or type below. Use
second page for additional information or comments.
| Name and Professional Degrees | |
| Title | |
| Institution or Company | |
| Preferred Contact | Home Office |
| Street Address | |
| City, State, Zip | |
| Office Telephone | |
| Office Fax | |
| Home Telephone | |
| Mobile Telephone | |
| Specialty 1 | |
| Specialty 2 | |
| Other Expertise | |
| Social Security or Tax ID No. | |
| States Licensed | |
| Fees (Hourly or Specify) | Case Review $_______ Deposition $______ |
|
|
Trial Testimony $______ Other $_______ |
| Any adverse reports in the National Practitioners Data Bank? |
No
Yes If yes, please explain on second page. |
| Experience as Expert? |
No
Yes If yes, please note
approximate number and general nature of cases on second page. |
| Retired? How Long? | No Yes |
| Do you do independent medical examinations (IME)? | No Yes If yes, list fees: |
| Willing to do medical review at $150 per hour? | No Yes |
| Travel Restrictions | |
| Willing to testify in court? | No Yes |
| Willing to do medical malpractice cases? | No Defense Only Plaintiff and Defense |
© Copyright 2006-2007 by
MedicoLegal Consultants. All rights reserved.