McDonald & Associates Referral Request Form

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Please provide as much information as possible

Client Information-

Name - First:

Last:

Phone#:

email Address:

FAX#:

If returning Client, just enter account number

(No address info required)

Company:

Address:

City:

State:

Postal Code:

Case Budget:

Date Report Required:

Type of Service Required

uRecorded Statements

uAccident Scene Analysis

Claimant	Telephone	Diagram of Accident Scene
Witness	In-Person	Still Photography of Accident Scene
Supervisor	Transcribed	Video Photography of Accident Scene

uMedical Records Retrieval

uActivity Check/Background Check

All Prior Records

Activity Check with drive-by & area photos

Review Records	Background Check Only
Related Records Only	Specific (i.e. Criminal Hx, Claims Hx, etc.)
Search by Facility Type (please specify)

uSurveillance

Document activities (Video & Still Photography)

Claimant Information

Claim#:

DOI:

Type of Injury:

Name- First:

Middle:

Last:

Address:

City:

State:

Postal Code:

Physical Description:

SSN:

DOB:

Phone#:

Work#:

Employer:		Contact:
Claimant on time loss
Claimant has legal rep
Attorney:		Phone:

Remarks / Specific Information Request

Please provide as much information as possible.

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